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TEXT-BOOK

OBSTETRICS

BARTON COOKE HIRST, M.D.

PROFKSSOR OF OBSTETRICS IN THK UNIVERSITY OF PENNSYLVANIA

Mitb o33 1!Uu5trations

SECOND EDITION

• ••

• • • •

• •

'• • • •

• • •

• •

PHII ADELI'HIA

W. B. SAUNDERS

925 Wai.mt Sfrkkt

I QOO

■^a-

CapyRiGHT, 1899, ^ ^' ^' Saundrrr.

• * fe » • •

• • » » »

••• • • ••• • • •

• • • • ••••••

••• • • •••••••

••• • •••••••

••••••• •••• •• •••

Mius or

«. •. SAUNOm. FHILAOA.

\<30 0

RICHARD A. F. PENROSE, M.D., LL.D.

EMERITI'S PROFESSOR OF OBSTETRICS AND OF THE DISEASES OF WOMEN AND
CHILDREN IN THE l-NIVERSITY OF PENNSYLVANIA

^bi0 JSooTi ie <3tatetulli? Dedicated

BY HIS FORMER PUPIL, THE AUTHOR

43463

PREFACE TO THE SECOND EDITION.

The exhaustion of a large edition of this work in a few
months is naturally very gratifying to the author. No exten-
sive alterations have been made, and no revision has been
attempted. A few typographical errors and inaccurate state-
ments, inevitable in a first edition, have been corrected.

The linglish equivalents of metric measurements have been
added throughout the book, except in the section on Pelvimetry
and Deformities of the Pelvis, where they have been purposely
omitted, for the reasons that it is most desirable to have a
uniform standard throughout the civilized world ; that the best
work in the study of deformities of the pelvis is found in the
Continental countries using the metric system ; that this system
is the most scientificallv accurate, and on account of its minute
divisibility, convenient ; and that the pelvimeters in common use
are graded in centimeters.

PREFACE.

This work is the result of a practice devoted for the past
twelve years exclusively to gynecology in both its branches —
obstetrics and gynecic surger>\ The author has served during
this period as consulting and attendant gynecologist and obstet-
rician in eight of the principal hospitals of Philadelphia. His
experience in obstetrical complications and operations has con-
sequently been exceptionally large. He has been engaged,
moreover, during the whole of his professional career, in
teaching medical students in clinics, hospitals, laboratories, and
in the lecture-room. He ventures to entertain the hope, there-
fore, that his training has fitted him for the preparation of a
book which shall serve as a guide to undergraduate students and
to physicians in active practice. It has been his constant aim to
condense the text as far as is consistent with a comprehensive
treatment of the subject. Illustrations have been extensively
employed, the majority of them from original photographs
and drawings. The task, impossible within a single volume, of
presenting a complete bibliography of each subject has not been
attempted. The student who desires such information is referred
to the "Catalogue of the Surgeon-General's Librar>%" the ten
volumes of the ** Jahresbericht iiber die Fortschritte auf dem
Gebiete der Geburtshilfe und der Gyniikologie," and to the ** In-
dex Medicus." References are given to articles and books
which have been most helpful to the author or which have been
epoch-making in the history of obstetrics.

1821 Spruce Street, Philadeli'Hia,
November, 1898.

CONTENTS.

PAGB

Introductory 17

Chapter I. — Anatomy 17

Anatomy of the Pelvis 1 7

The Female Sexual Organs "39

Chapter II. — Menstruation, Ovulation, Fertilization, etc. . 56

Menstruation 56

Ovulation • • 59

The Corpu> Luteum 62

The Connection between Ovulmion and Menstruation 63

Insemination 64

Changes in the Ovum following Impregnation 72

PART I.— PREGNANCY 74

Chapter III. — The Development of the Embryo and Fetus . 74

Development during the Months of Pregnancy 74

The Mature Fetus 85

Chapter IV. — The Fetal Appendages 91

The .\mnion 92

The Chorion I03

The Placenta 112

The Umbilical Cord 132

The Decidux' 139

Chapter V. — The Diskases of the Fltts 151

Chapter VI. — The Physiology of Pregnancy 181

Changes in the Ulenis 181

Changes in the Several Systems of the Pixly 186

The Diagnf»is of Pregnancy 189

Chai»ter VII. — Pathology of the Pregnant Woman 210

Diseases of the (ienitalia 2IO

Diseases of the Uterine Muscle 215

Diseases of the Alimcntarv Uanal 221

Diseases of the Urinary Apparatus 226

Diseases o( the Nervous System 232

Diseases of the Circulatory Apparatus 236

Diseases of the Respiratory Aj)paratu5 238

Diseases of the O-^seous System 240

Infectious Diseases 240

Skin Diseases 241

Abortion, Miscarriage, and Premature Lalx)r 243

Extra-uterine Pregnancy 259

1 4 CONTENTS,

PAGE

PART II.— THE PHYSIOLOGY AND MANAGEMENT OF

LABOR AND OF THE PUERPERIUM 285

Chaiter I. — Labor 285

Chapter II. — The Puerperal State 319

PART III.— THE MECHANISM OF LABOR 350

Forces Involved in the Mechanism of I^bor 354

Mechanism of the Several Presentations and Positions 357

Abnormalities in Mechanism and their Management 364

Mechanism of the Third Stage of Labor 395

PART IV.— THE PATHOLOGY OF LABOR 401

Chapter I. — Dystocia 401

Abnormalities in the Forces of Labor 401

lAlK)r Complicated by Accidents and Diseases 525

Dystocia Due to Disease 57^

PART v.— PATHOLOGY OF THE PUERPERIUM 584

Chapter I.

Abnormalities in the Involution of the Uterus after Child-birth . 584

Puerperal Hemorrhages 590

Non -infectious Fevers 607

Acute Intercurrent AtTcclioiis 615

The Exanlliemata 617

Puerperal Malaria 626

Rheumatism and Arthritis 629

(ionorrhea 631

Skin Diseases 632

Tympanites •. . . . 632

Diseases of the Urinary System 634

Diseases of the Nervous System 640

Developmental Anomalies of the Breast 641

Anomalies in Milk Secretion 644

Diseases of the Mammary Glands 652

Relaxation of the Pelvic Joints 658

Chapter II. — Puerperal Sepsis 659

PART VI.— OBSTETRIC OPERATIONS 719

Induction of Abortion 719

Induction of I^bor 721

Forceps 722

Extraction of the Breech . 745

Artificial Di 748

VersioQ «<4

CONTENTS, 1 5

PAGE

Embryotomy 767

Symphyseotomy 774

Cesarean Section 779

PART VII.— THE NEW-BORN INFANT 789

Chapter I. — Physiology of the New-born Infant 789

Chapter II. — Pathology of the New-born Infant 799

. Injuries to the Infant during Labor 799

Diseases of the New-bom Infant 808

A TEXT-BOOK

OBSTETRICS

PART I.
PREGNANCY*

CHAPTER I.

Anatomy of the Pelvis; Devebpment and Anatomy of the

Female Generative Organs*

THE ANATOMY OF THE PELVIS.

The hip-bones together with the sacrum, including the
coccyx, compose the pelvis, which forms the basin-like lower
portion of the trunk. In the erect position of the body the
pelvis is bent obliquely backward from the vertebral column
above, so that the crest of the pubis descends nearly to a level
with the end of the sacrum. The pelvis is divided into two parts
by a prominent rim, named the brim of the pelvis, which is
formed on each side by the iliopectineal line continued behind
the crest of the pubis and by the curved ridge and promontory
of the sacrum. The upper part is formed by the ilia, and
includes the widest space of the pelvis which pertains to the
abdominal cavity. The lower part is distinguished as the true
pelvis, and incloses the cavity of the pelvis. It is a complete
bony girdle, formed by the sacrum and coccyx, the ischium and
pubis, and a small portion of the ilium. The upper extremity
of the pelvic cavity, corresponding with the brim, is the inlet, or
superior strait ; the lower extremity is the outlet, or inferior
strait. In consequence of the curvature of the sacrum and
2 17

IS PREGNANCY.

coccyx the pelvic cavity appears as a curved cylinder, slightly
narrowed toward the outlet. It is deepest behind and shallowest
at the pubic symphysis. Its lateral wall is deep and vertical.
It extends from the iliopectineal line to the end of the ischial
tuberosity, and is mainly formed by the body of the ischium
with small portions of the iUum and pubis. The anterior depth
of the pelvis (height of the symphysis) is 4 cm. (1.57 in.). The
lateral depth is 9 cm. (3.54 in.). The posterior depth is 13 cm.
(5.13 in.).

The pelvic inlet is cordiform, with the notched base con-
forming with the base of the sacrum and the rounded apex
with the pubes. The outlet, rather smaller than the inlet, when
completed by the great sacrosciatic ligaments has the same
shape, with the notched base formed by the coccyx and the apex

by the pubic symphysis. Its fore part is the pubic arch, the
base of which extends between the ischial tuberosities ; and ihc
sides are formed by the conjoined rami of the pubes and isciiia.
On each side of the outlet is the deep sacrosciatic notch, fonned
in front by the ischium, above by the ilium, and behind by the
sacrum and coccy.v. It is converted into the great and small
sciatic foramina by the sacrosciatic ligaments, which also sepa-
rate them from the pelvic outlet. The pelvis of the female not •
kionly differs from that of the male in accordance with the usual
(difference >- '•*•- skeleton, but also exhibits impor-

to the .sexual function. The
ma) 'cr, but of more delicate con-

THE ANATOMY OF THE PELVIS. 19

struction. It is proportionately, and often absolutely, of greater
breadth, and is of less depth. The ilia spread more laterally, so
as to produce greater breadth or prominence of the hips than in
the male. The true pelvis has greater horizontal capacity, less
depth, and is commonly less curved and less contracted at the
outlet. The inlet is larger, less intruded upon by the sacral
promontory, and is more circular or transversely oval. The
outlet is likewise larger, with the ischial tuberosities less cdnver-
gent, and with the pubic arch wider, lower, more truly arched,
and with the sides more everted.

— Tlir fmuiel shaped Tal;

In the female the sides of the pubic arch are narrower, more
flattened, and loss ridged than in the male.'

The hip or innominate bones — in the adult a single piece —
are composed, in fetal life and in childhood, of three separate
bones. — ^the ilium, the ischium, and the pubis. The three bones
are united by a triradiate cartilage in the acetabulum, which
begins to ossify at puberty, the ankylosis being complete in the
eighteenth year. The descending ramus of the pubis and the

" AnWomy.

This iirief nnWomical description of the pelvis is Htm, modified, from Leidy'*

PKEG.VAyCY.

ramus of the ischium are also on'giiuily united b>' a cartilage
which ossifies at about the eighth )'ear.

TIm Afialomy of the Pelvis Obstelrically Considered. — To

the obstctrioan the pcKis is a canal and not a basin, and i^ to be
studied mainly in its relation to the fetal bodj- which must
pass through iL The false peKis is of minor importance, acting
simpl)' as a (iinnd-shaped structure to direct the presenting part
toward and into the superior strait of the true pcl\is. The
obstetrical study of pelvic anatomy maj- be confined to the
shape, size, position, and direction of the true pelvis.

Pelvic Skapc — If one were forced to define the shape of the
pelvis he might describe it as a truncated cjlinder, but the

Fig. 3. — Tic shape of the superior

description would not be exactly accurate. As a matter of fact,
the pelvic canal is of different shape at diflerent le\'els, and it
is necessary to studj' certain tv-pical planes of the pelvis in
order to understand fully the relationship of fetal to pelvic
shape in labor. The first of these imaginary planes is laid at
the entrance to the pelvic cavit>' or canal, the peh-ic inlet or
k niperior stt^^.WdrftJWMW^ ^>' ^^'^ pronioiitor\' of the sacrum,
> of tlte pubis, and the upper
5 of the pelvic inlet is cordi-
f the promontory rest the
I of the pelvis, where
f tbe fclal head- It «-as

THE ANATOMY OF THE PELVIS.

thought formerly that the shape of the pelvic inlet was elliptical,
but this is only exceptionally the case, as in certain justominor
pelves, in which the nervc-trunks and vessels may be subjected
to such excessive pressure that disease and disability result.

In studying the pelvic canal from above downward it
appears that the canal expands below the pelvic inlet and then
contracts again as it approaches the outlet. It is convenient.
therefore, to lay off a plane at the level of greatest expansion
and anotherat the level of greatest contraction, which are called,
respectively, the plane of pelvic expansion and the plane of
pelvic contraction. The shape of the pelvic canal at the plane
of pelvic expansion, passing through the middle of the sym-

Fiy, 4, — The Ji

physis, the top of the acctabula. and the sacrum, between the
second and third vertebra;, is almost exactly circular, being only
a trifle larger in its anteroposterior than in its transverse diameter.
The shape of the pelvic canal at the plane of pelvic contraction,
passing through the tip of the sacrum, the spines of the ischia,
and the lower surface of the symphysis, is distinctly elliptical.
being a centimeter longer anteroposteriorly than it is transversely.
Finally, the shape of the pelvic outlet, or inferior strait, is
cordiform, from the projection forward of the tip of the sacrum
and the coccyx.

22 PREGNAXCY,

Pelvic Size. — In determining the size of an irregularly shaped
canal like that of the pelvis it is neccssar>' again to resort to
certain typical planes at different levels, and to measure typical
diameters in these planes. Beginning with the cordiform pelvic
inlet it is obvious that its dimensions may best be expressed by
the following diameters : An anteroposterior diameter measured
from the middle of the promontory of the sacrum to the sym-
physis pubis, about 3.17 mm. (^ in.) below its upper edge;
this measurement averages, in the well-dcvcloix:d Caucasian
woman, 1 1 cm. (4.33 in.).

A transverse diameter^ the longest distance from side to side of
the pelvic inlet, measuring on the average 13.5 cm. (5.32 in.), and
two oblique diameters, the right from the top of the right, the left
from the top of the left .sacro-iliac junction to the opposite ilio-
pectineal eminences, measuring 12.75 c"^- (5-02 in.). At the
plane of pelvic expansion it is j)(>ssible to measure but two
diameters, an anteroposterior and a transverse ; the former is
12.75 cm. (5.02 in.), the latter, 12.5 cm. (4.92 in.).

At the plane of pelvic contraction the anteroposterior diam-
eter is 1 1.5 cm. (4.43 in.), the transverse, 10.5 cm. (4.13 in.). At
the inferior .strait the anteroposterior diameter, measured from the
tip of the coccyx to the lower i:i\\^^ of the symphysis pubis, is 9.5
cm. (3.74 in.) ; but this is not a fi.xed measurement, as the coccyx is
normally movable and is displaced backward in labor ; the obstet-
rical anteroj)osteri()r diameter, therefore, is measured from the
tip of the .sacrum to the lower edge of the symphysis pubis ; it is
II cm. (4.33 in.)ij. The transverse diameter, measured from one
to the other tulxrrosity of the ischium, is 1 1 cm. (4.33 in.).

Pelvic Position. — By pelvic position is meant the angle or
inclination of the pelvis to the trunk and to the horizon. The
inclination of the plane of the superior strait to the horizon, as the
individual stands erect, is fifty-five degrees, and of the inferior strait,
ten degrees. The inclination of the pelvis, however, changes with
changes of posture. It disappears in a squatting or sitting posture,
and is increased if the individual leans backward. The greater
the inclination of the pelvis, the more the axis of the superior
strait diverges from the long axis of the uterine cavity, and con-
sequently the greater must be the divergence in direction of the
presenting part from that of the rest of the fetal body when the
former engages in the superior strait. Much stress was once
laid upon this &ct, but, by placing a woman upon her side and
flpv ■ "Don the trunk, the inclination of the pelvis is

'disappear. The obliquity of the pelvis,

lously considered, as a rule, in labor,

of the pelvis as the woman stands

fcunt if one would understand the

THE AKATOMV OF THE PELVIS.

pelvic deformities of rachitis, lordosis, kyphosis, spondylolis-
thesis, and osteomalacia ; some of the anomalies of labor in
these pelvic deformities ; and die abnormal relations of the ex-

24 PKEGXANCY.

tcrnal genitalia to the pelvis, whenever the latter shows- an
excessive or deficient inclination.

Pelvic Direction. — By this term is meant the direction of the
pelvic canal. It was the custom in a former generation to
express pelvic direction by an exceedingly complicated mathe-
matical formula, yielding what was called the ** curve of Carus.''
Not only is this formula unnecessarily complicated, but it is also
incorrect. The direction of the pelvic canal depends entirely
upon the cur\'e of the sacrum, and this differs in every pelvis.
Taking, at random, any half-dozen or so of sacra from my col-
lection, the utmost diversity of cur\'ature is seen. The direction
of the pelvis ma\' be described with approximate accuracy as a
line parallel with the sacral curxe, and equally distant at all
points from the pelvic walls.

The Development of the Pelvis. — It may be easier to understand
the peculiarities of the adult pelvis if one considers the forces
imposed upon it and tlicir influence upon the individual bones
and upon the ptK is as a whole. The pelvis is subjected to the
weight of the trunk imi)oscd upon it from above, the counter-
pressure of tlie limbs below, and the pull of powerful ligaments,
muscU^s, and joints. The weight of tlie trunk, transmitted from
above downward and from behind forward, tilts the sacrum forward
by a rotary movement on its transverse axis and confers upon it
the characteristic position or inclination. This force, however
is resisted by the ])ull of the muscular and ligamentous con-
nections lietween the trochanters of tlie femora and the tuber-
osities of the ischia and l)y the pressure of the heads of the
femora on the acetabula. By the former force the tuberosities
of the ischia are pulled apart and the normal width of the pelvic
outlet is secured. The sacrum bears the greatest weight of the
trunk, and in conse(iuence its top is forced downward and for-
ward. The natural consequence would be to tilt the lower end
of the sacrum and the coccyx backward, but they are subjected
to the i)owerful pull forward of the ligaments and muscles
attached to them and to the lateral and anterior pelvic walls.
Hence the sacrum, subjected to these two opposing forces, is
bent like a bow between them, and thus acquires its perpendicular
curve. As the upper portion of the sacrum moves downward
and forward, it drags with it the posterior superior portions of
the iliac bones, to which it is attached by the sacro-iliac junctions
and by the strong sacro-iliac ligaments. The natural result of
the movement of the posterior portions of the innominate bones
inward, downward, and forward, would be to throw outward the
anterior extremities of these bones, and this would happen were
not the bones joined firmly at the symphysis. Subjected to the

THE ANA TOMY OF THE PEL VIS,

force behind and restrained by their junction in front, the innomi-
nate bones are bent upon themselves, and thus acquire their
lateral curve.

These few illustrations by no means exhaust the dynamics of
the pelvis. The subject will be referred to again in the study of
some of the pelvic deformities.

The Bony Pelvis in Life Filled with Soft Tissues. — Besides
the generative organs, the obstetrical anatomy of the pelvis must

Fig. 7. — ^The pull of the ligaments and the pressure of the femora upon the pelvis

(Schroeder) .

take into account the muscles, ligaments, connective tissue,
blood-vessels, lymphatics, and nerves.

The Muscles. — The iliopsoas, the obturator intemus, and the
pyriformis clothe the pelvic walls, modifying the diameters of
the pelvic cavity and acting as buffers or cushions to protect the
child's body in its passage through the birth-canal. The bulky
iliopsoas muscles diminish the transverse diameter of the pelvic
inlet by 5 cm. (2 in.), thus making the oblique diameters of the

26 fXEOXAXCy.

[iolvic inlet the lonj:;est and insuring ordinarily an oblique position
of the prvseniinjj part, but these muscles are subject to compres-
sion and to sonic disijlaccment under pressure in labor, and, if
the prcssuiv is excessive, the transicrse diameter again becomes
the ionijesl : hence the transverse position of the head in ob-
structeil labors. The cocc\geus, the le\ator ani, the retractor ani.
the sphinclif ani. the constrictor vagina;, and the transversus
jx'rinei arc the muscles of the pelvic floor giving the direction to

the lower part of the parturient tract in labor and directing the
presenting part forward, outward, and upward under the pubic
arch. The levator ani is by far the most important muscle in the
pelvic floor. It is a strong, horseshoe-shaped band of muscle,
consisting of two symmetrical halves slung back from the anterior
pelvic wall and surrounding the vagina and rectum. It is the
chief factor in pushing the presenting part forward away from the

THE ANATOMY OF THE PELVIS.

perineum and out through the vulvar orifice. It is thus the chief
conservator of the integrity of the pelvic floor in labor. Its injury
robs the rectum and posterior vaginal wall of their strongest sup-
port, allowing them to drop downward, outward, and forward in
the rectocele, with which the gynecologist has to deal in second-
ary operations upon so-called lacerations of the perineum.

The ligamentous structures of the pelvis of greatest interest to
the obstetrician are the obturator membranes and the sacrosciattc
ligaments, which close the pelvic walls, help to impart to the
canal its shape and direction, and, by their situation at either end
of the oblique diameters, receive upon their yielding surfaces the
greatest pressure from the extremities of the long diameters of
the fetal head, — an arrangement much more favorable for the child

mEtSAANCV.

than would be the compression of the longest diameters of the
head between bony pelvic walls.

The Connective Tissue of the Pelvis. — An intimate knowledge
of the complex arrangement of the pelvic fascia is not essential

iilachments of the IcTstores ■

to the obstetrician. For his purpose it suffices to remember that
the arrangement of the ptlvic connective tissue may be compared
roughly speaking, to a six-]>ointcd star centering at the uterus,
the three arms on each side being disposed as follows : A lateral

muscles from before and billow

arm running out fnini tlie iilcriw liflween the layers of the broad
li[ramcntan(! licconiing I'lnUiiuiiiiin with the. niibperitoneal connect-
ive tis.sue of the Litrriil pt-Ivlf Willi ; iin anterior arm skirting the
bladder; a poHlcrior itri)) MkJrtinc the rectum and continuing in

THE ANATOMY OF THE PELVIS.

Fig. 12. — Schematic representation of the superior strait: rt, Promontory;
b, symphysis; I, I, iliopsoas muscles; 2, 2, rectus abdominis; dotted line, the
pelvic inlet (Veit).

F'g- '3- — T^® plane of pelvic expansion : //, Sacrum ; b^ pubis ; r, lateral
pelvic wall; I, I, pyriformis; 2, 2, obturator intemus ; w, w, obturator membrane;
t, f, sciatic nerve.

PKEGNANCY.

liH- I4.-ni<"<-->f !■

of sacrum ; ^, b, afcendEng ramus of

THE AA'ATOMY OF THE PELVIS. 31

F'g> '7> — The pelvic ligameiils from aliove : n, '\\\t of satrum : *, sulipubic
ligament ; 1-, luber ischii ; .1'. fuicroE-ciatJc iiolch ; e, ajienure for fcinural vF^acl.'i and
nerves ; /i, Poupan's ]ii;i"iiotit (Hart).

32 PRKGNAI^CY.

the mcsorectum to the posterior pelvic waJJ. Branching pn
cesses, in addition, follow the round Jig-ament to the ^roin an
mons veneris, the vessels and nerves escaping- through the saiCro

sciatic notch to the buttocks, the three canals of the peJvis

the urethra, vagina, and rectum — to the subcutaneous connec-
tive tissue of the external genitalia and perineum.

The Blood-vessels. — The ovarian arteries, leaving the aorta,
enter the pelvis on their respective sides and, passing between tht
laminie of the broad ligament a short distance under its upper
edge, send branches to the ovaries and tubes and a branch to t\\t
fundus, while the main trunk turns at a right angJe downward
alongside the uterus, to anastomose with the uterine artery giv-
ing off on its way numerous branches to the uterine walJ. The
uterine artery on both sides passes downward from t\\G anterior
trunk of the internal iliac to the neck of the uterus, ^W\n^ off a
large branch to the lower uterine segment and cervix, the circu-
lar artery of the cervix, and numerous smaller branches to the
uterine wall as it rises to meet the ovarian artery. The veins of
the pelvic organs of chief interest to the obstetrician are the Jarge
trunks between the layers of the broad ligament alongside the
uterus and the complicated pampiniform plexuses in the neigh-
borhood of* the ovaries.

The lymphatic ducts of the pelvic organs are of interest mainly
in the part they play in the absor])tion of the involuting uterus
and by conveying septic micro-organisms and the products of
their activity into the system. The lymph-spaces of the uterus,
lying between connective-tissue bundles and clothed with endo-
thelial cells, empty by means of ducts into the pelvic system of
lymphatic glands. The most important groups of the pelvic
lymphatic glands are the uterine, obturator, hypogastric, lumbar,
sacral, and inguinal. It is interesting to note that the lymphatic
ducts of the lower fourth of the vagina terminate in the inguinal
glands. The enlargement, inflammation, and suppuration of the
inguinal glands, therefore, indicate infection of the parturient outlet.

The nerves of the generative organs are derived from the
spinal and the sympathetic systems. The sexual processes,
however, of ovulation and of menstruation and the action of the
uterine muscle in labor are controlled by the sympathetic nerves,
derived mainly from the hypogastric and ovarian plexuses. The
clinical observation that paralysis of the spinal nerves supplying
the pelvic organs in nowise interferes with gestation and labor,
and the experiments on bitches of resecting the lumbar cord and
seeing the animals exhibit rut, become gravid, and bear pups,
show what a subordinate part the spinal nerves play in the sexual
processes of the female.

THE ANATOMY OF THE PELVIH.

Fig, 19.^ — The arleiic* of ihe uterus nnd ovaries: O.A.. Ovarian artery; h, artery
of Ihe rounil ligsmeiil ; /''. branch tn Ihe lulie ; <". i", !■, brnnehea lo Ihe ovary;
4. conlinualion of mnin Iruiik ; 1. branch lo ihe Coriiu ; L'.A., uterine urfery ; <. main
trunk ; f, hiFurcalion ; g, vagina! branchea 1 h, vnginal branch ixoa\ the cervical

artery (Hyrtl).

PXEGXAXCV.

Fig. 33. — Lymphatics of the pcU'ic viscera and abdomen!
erira; C, C, tiie bifurcalion and two branches r.f ihe iliac ai
E, left renal »eiii ; F. right renal vein ; G. iliac veins ; H. H, l
K, nterusi L, cervix; M, M, vagina] walls; N, N. FallnpiHii tubes; P, P, i
Q, Q, round ligaments; I, Deep Ijrmphnlic vessels of the right kidney, and ganglia
into which they empty ; 2, 2, 2, 2, superficial lymphatic vessels ; 3, 3, 3, 3, the same ;
4. two ganglia thai receive these superficial vessels; 7,7, sutiovarian plexus of
lymphatics; E, S, ducts leading from this plexus ; 9, 9, the same ; lO, 10, II, II, glands
receiving these ducts; 12, 12, 12, 12, lyraphnlie ducts, originatioK in the fundus uteri,
and terminating in the same glands as the ovarian ducts; 13,13, ducts from the
anterior surface and sides of the uterus; 14,14, glands into which (hey empty;
■5.15, ducts originaliog in cervix and upper part of vagina 1 16,16, glands into
which they empty ; 17, 17, efierent vessels of these glands ; 18, 18, Ijinphfllic ducts
fwm posterior surface of the uterus and glands into which they empty ; 19, lumbar
gland (exceptionall ; 20, gland into whic£ occasionally a duct from lower uterine
segment empties (Sappey).

PREGNANCY.

Rg. i\. — The nerves of ihc pelvis; A, AbdomitiHl aortn; B, lumbar vertebrte
villi inlervencbral duic^; C. the riijht pailion nf [he Mcruin sawn ufler removal of as
iaDomiaBlum i D, urcler ; E, pyrifomiii muscle cut U iU esil from (he pelvic civUy ;
A, tbe curve of llie rectum, corresponding to ihe Biilerior uirfnce of ihe sacrum ; H,
Tir^nal uterui feebly <1eve1apefJ \ IC, nghl ovary displaced wmewhal upward ; L,
bladder ; M, levator ani inuicle. cul in put ; A', Uchiocavemosus muscle ; O, corpus
cavemowm ditoridls, joininR on the other side Ihe clilorii, covered with ncrve-filn-
menti; ^, symphyaiapubis{the whole body being inclined forward, it has become hnri-
(ontal); T, iiniuriated end of Fallopian lube; I, I, Liimiar Hrnts , p.issing out of Ihe
interrertebral foramina to form tYte iumkar /ifexus ; the tower luinbnr and ihe upper sacral
oems joiDinf; to form the laeral /ilrxuitn front of the pyrifonni! muscle; 3, sacrol
pleiusi iif/u/ftinertvscM: the/uc/jroi-nf springing l)y several tools from the pleiiis

THE ANATOMY OF THE PELVIS.

jrvea; 5, fine twigs passing fnjin the pudic tier»e 10 Ihe
malti iruiik k"'!" under the symphysis, and ends as ifae
; 6, 6, hmnchi^sof cfuninuiiiCBtifiti which carry sympathe-
id spinal twigs lo the hypogaalric plexus of the sympalhe-
"ifMielii'm front of the lumbar vertebra; S, c

formed by Ibe lower sacml n
ischiocaTemosus muscle; the

donalnr-rr/ 0/ Iht clilBrii (2i
tic twigs Id the spinal nerves 11
tit; 7.ptincipaltninkoflhei>

of ihesympatheliciit front of ihesncnim; 9, 9, aortic pleicus : 10, kemorrkiiiiial pit
following ihe arteries of the same name; II, tuptrior ky/egastric fUxus,tx iUtkyfie-
gailrit pIiiHs, which receives many spinal and sympathetic branches 1 12, mfiriar
irfojfiutric f/fjui, coniinnnicaljng with 13, anttrior san al />le.tus , made up of spinal
■nd sympalhelic branches -, 14, from the many ganglia placed in this plexus it hat a
nelworL appearance ; 15, inferior reclnl twigi, which |ia»>down even tu Ihesphinctcr,
where ihey form a network covered by the levator ani ; 16, i«^W///?Jiu/ 17, that
part of the inferior hypogastric plemisin the shape of a line network at the upper end
of ihe vagina gives htancbes lo Ihe bladder, the Fallopian tube, and the clitoris { tS,
nenre twigs which run on the side wall of Ihe uterus, giving bnnchcs to it, upwaid
to the Fallo^an tube and ovary, where they join Ihe nerves following the ovarian
■nery, which correspond to the spermatic plexus in man ; 19. vesical nerves ; 30,
mlfrine pleiui : 2\.dorsiil ntri'i of cliloj U. ti\A<^ joins with the tavtrttaui flt-xvi
b/ tht ititerii from the sympathetic lo ihe glans cliloridi, (Rydygier).

PREGA'AA'CV.

superior hypc^astric plexus; 13, branches from hypogiistric plexus (o uterus; 14.
inferior hy|>iignhLric plexus ; IJ, vesical nerves; 16, ccuninuni eating branches lo vesical
plexus; 17, cervical gaiiglicin ; iS, branches of hypogaslric plexus to cervical ganglion ;
19, first sacral nt-rvp ; 30, brandies passing to bladder; al, brandies passing between
bladder and rcelum ; 12, cDmniiuii eating bnnches Iron) second sacral to cervical
ganglion ; 23, liranch from third sacral nerve to cervical eangllon ; 24, second sacral
serve; ij, Innnchei from third tacial nerve to vagina and bladder; 26, brunches
poising titom fourth aacral 10 cervical ganglion (Fcankenhfiusen).

THE FEMALE SEXUAL ORGANS.

The development of the sexual orjjans may be briefly de-
scribed as follows :

The development of the genito-urinary organs up to a certain
point is common in both sexes. In late stages the duct of Wolff
almost disappears in the female, while in the male it constitutes the
vas deferens ; the Mullerian ducts, on the contrary, atrophy in tlie
male, but form Fallopian tubes, uterus, and vagina in the female.

The accompanying illustrations (,I"igs, 37, 38, 29, and 30J
may aid the student to understand the subdivision of the primary
cloacal chamber. As they refer to the female embrj'o. the
Wolffian ducts are omitted.

nicsies with the rccluni and allantois ; Ihe poslerior fiurtion. all, of Ihe loller has
commenced to dilale lo form the urinaij bladder; m, duct of Mflllet ; r, rectum.

Fig. 28. — The cloaca has divid»l into a vpnlml portion, j». the urogenital
Mnus, which conununicales rentrally with the urethra, n, and the bladder, b, and
more dorsally with i', the vagina, formed by fusion of the duMs of MUUer; r, rectum.

Fig. 29. — The perineum or tissues separating Ihe rectum from the urogenital
■inus are well developed ; the neck of the bladder has become constricted to form Ihe
primitive urethra, and is separaled from the vaginal passage, Ihongh both open into
thfl common urogenital stnui, 1. and ihe clitoria, c (in the male the rudiment of the
penis), has appeared ; r, rectum.

F'ig. 30.— Thr urogenital sinus of the female, /. remains as Ihe cleft between the
sides of (he exlemol aperture of the labia minora 1 it communicates in front with the
bladder. *, and dotsally with ihe vagina, t; r, rectum.

The essential sexual glands develop in both sexes in close
association with the ducts of Wolff and MuUer, and in the neigh-
borhood of the mesonephros. The cells lining the abdominal
region of the primitive celom early become differentiated as its
lining epithelium: in most regions they quickly become flat
scales, but over the bulging of the intermediate cell-mass they
enlarge and become columnar in form. These enlarged cells
remain for some time over all of the projecting surface of the
intermediate cell-mass, and even extend beyond it upon the outer
side of the developing mesentery. They soon become flattened
over most of the mass, but remain columnar and multiply for
some time on its inner and outer sides. On the latter they give

PREGNANCY,

origin to the Miillerian duct and some segmental tubes and soon
cease to be distinct ; on the former they constitute the primi-
tive germinal epithelium. The mesoblast lying beneath this
epithelium gives rise to the blood-vessels and connective tissue
(stroma) of the ovary or testis, as the case may be. At this
stage it is difficult or impossible to detect the sex of the em-
bryo from the structure of the sexual glands.

In the female some cells of the germinal epithelium enlarge to
form the primitive ova. Surrounded by other cells from the germi-
nal epithelium, they grow into the ovarian stroma as the egg-tubes
or cords and give rise to the primitive Graafian follicles.

Fig. 31. — Diagrams to illustrate the develoiimeiil of tlie internal genital orj^ans
in both sexes. I, llennaphnxlite or undilTerentiatctl ccMiiliiion : </, Ovary or testis
lying upon the tubules of the WoHTian Im^Iv; /(', Wolfiian duct ; JA duct of MUlIer*
S^ urogenital sinus. 2, Moditkations in the female : 'I\ I'riniitive Miillerian duct
forming the Fallopian tube and develojiin^' timhria-, /, around its peritoneal oj>ening •
h\ ovarian hydatid ; i\ uteru-> formed hy fusion of the |)osterior ends of the ducts of
MUller; .S", urogenital siiuis ; (> (an>\veriiit; to D in I), ovary; /*, parovarium, or
remnant of Wolffian l)ody and duct. 3, Modifications in the male : H^ Testis
(corresponding to /) in I) ; A', epididymis; //, hydatid of Morgagni ; a^ vas aberrans ;
K, vas deferens, or Wolffian duct ; //, uterus masculinus, the remnant of the lower
ends of the fused ducts of Miiller; .S', urogenital sinus (from Landois and Stirling).

The testicle is distinguishable from the fetal ovary about the
eighth week. The cells which in the female form ova, in the
male subdivide and give origin to the spermatozoa, while the
celljl^vhich correspond to the lining cells of the female egg-tubes
develop the lining cells of the seminiferous tubules. These
canals may be detected in the human embryo of ten weeks ; they
branch, and during the third month are collected into groups,
indicating the lobular subdivision of the adult testis.

The genital cord is a cylindrical mass in w^hich, in both sexes,
the ducts of Miiller and Wolff become imbedded near the uro-
genital sinus. The four ducts (two from each side) are at first

THE FEMALE SEXUAL ORGANS.

separate. The Miillerian ducts coalesce at their lower ends and
in the female enlarge to form the vagina and the posterior por-
tion of the uterus ; in the male the lower fused portions of Miil-
lerian ducts remain as the prostatic vesicle, or uterus masculinus.

Kig. 32, — Uiagrammalic outline of (he Wolffian bodies and Iheir relation to
[he ducta of MUller and Ihe reproduclive glands : ot. Seat of origin a! ovary or testes ;
w, Wolffian body; k. Wolffian duct; m, m, duct of Miiller; gc, genital cord-,
ug, urogenital ainus; 1', rectum ; el, cloaca (from Alien Thompson).

In the female the anterior portions of the ducts of Mijller
form the upper part of the body of the womb and the Fallopian
tubes. In the female the Wolffian ducts almost entirely disap-
pear, but traces of them may be found as the canals of Gartner.

PREGXANCY.

Pathological development and distention of these ducts some-
times j^ive rise to vaginal cysts, which may obstruct labor.

Meanwhile most of the Wolffian body (mesonephros) disap-
pears on each side, but remnants of it may be found in adults.
In the female they constitute the parovarium (epoophoron, or
body of Rosenmiiller).

The Development of the External Genitals. — ^The forma-
tion of the cloaca is conmion to both sexes, as is also its separa-
tion into an anal and a urogenital portion. The urogenital sinus
is at first narrow and deep, but soon becomes shallow, and
meanwhile the perineal tissues separate it more and more from
the anus. Before the subdivision of the cloaca a genital emi-
nence appears at its ventral or anterior end about the sixth
week. On each side <->f the cloacal slit outgrowths of skin and

V\^. 34. — 10 illu>ti itr the (It'vcloj)miiit cf llic liiiniaii external genitals: i. >J
Genital cniiiU'iRc ; /, il'uical ajxrtiirf ; v. tail cr coccyx of embryo. 2. k^ Genital
eminence;/-, cloacal o])<'iiinLi; r.', coinnunccnicnl of lahia majora or scrotum, accord-
ing toscx; .T, emhryonic tail. 3. Next stai^c, jiractically jK-rmanenl in the female • c
Genital eminence (clitoris); /, nyinplia' ; /., labia majora; o^ anus. 4. Later or
male condition: /', Penis; A', c<l^«'^ of embryonic folds enfolding to inclose the
penial urethra ; .S", scrotum ; n^ anus. 5 and (> illustrate the descent of the testicle
(from Landois and Stirling).

subcutaneous tissue (Fig. 34, i) become prominent. At the eighth
or ninth week there is a groove in the under (posterior) side of
the genital eminence, with well-marked side-walls leading back
to open into the cloaca. The development of the perineum
divides this groove (during the third month) transversely into a
smaller anal opening and a larger urogenital. This, cohdition
is but slightly modified in the female. The genital eminence
in that sex remains small and constitutes the clitofis. The side
walls remain separate and form the labia minora, while the cuta-
neous folds enlarge and become the labia majora (Fig. 34, 3).
The urogenital sinus is, therefore, permanent in woman, and forms
the vestibule, which has in front of it the clitoris, and, opening

THE FEMALE SEXUAL ORGANS.

into it, the urethra and vagina. The skinfolds remain separate in
the female to form the iabia majora.^

The genital organs and structures of woman are divided into
the external and the internal genitalia. The former, described
often as the genitalia, pudendum, or vulva, comprise the mons
veneris, the labia majora, the labia minora, the vestibule, with

^&|

IP^H^

^^W'^ jfl

MBSTpMC^^E,

B^rstlKe

'-1 1

|#L„,,«.'

njt

f^%.OK..

Fig- 35- — Diagram of the genitalia (Dickinson).

the urethral orifice, and the clitoris ; the latter, the hymen, the
vagina, the uterus, the Fallopian tubes, and the ovaries.

The Moiu Veneris and the Labia Malora.—* The mons veneris
is a flat protuberance over the symphysis pubis, consisting of
fat and connective tissue covered with a tough skin clothed with
coarse hair. In females the upper border of the hairy region

' The description of the devplopnKnt o( Ihe sexual organs is taken, wilh modifi-
cations, from Newel! Martin's article in '■ The American System of Obstetrics,"
edited by the author.

pregn:4ncy.

is a horizontal line ; in males the hair rises in a triangular
shape to a point upon the median line of the abdominal wall.
The labia majora are folds of skin containing fat, connective
tissue, and involuntary muscle-fibers, continuous with the mons
veneris and uniting below an inch in front of the anus. They
surround the urogenital fissure. Their points of junction above
and below are called the anterior and posterior commissures.
Just within the latter there is a crescentic transverse fold of skin,
called the fourchet. The region between the fourchct and the
posterior commissure is the fossa navicularis.

The Labia Minora, or Nymplis. — Just below the anterior com-
missure of the labia majora the nyniph.-e begin on each side as two
leaflets of dciicale skin ; one. the upper, with its fellow of the other

side, constituting the prepuce of the clitoris ; the lower leaflet,
with its other half, forming the frenum of the prepuce. Uniting
below and to the outer side of the clitoris, the nymph^e run
downward to merge into the labia majora at about their middle or
lower third. The labia minora are often asymmetrical. They lie
apposed to each other in the middle line, completely covered
by the labia majora. They vary much in size. In Hottentots
they are uniformly enormous, projecting far beyond the labia
majora. As an exception this condition is sometimes seen in
the Caucasian race. The skin of the nympha; is in a tran.silion
stage between mucous membrane and skin. It merges on its
outer side into the dehcate skin of the inner surface of the labia
majora, and on its inner side into the mucous membrane of the

THE FEMALE SEXUAL ORGANS. 45

vestibule. The venous spaces and the unstriped muscular fibers
in the nymphae resemble the structure of erectile tissue.

The vestibule is the space between the clitoris, nymphae, and
vaginal entrance. It is pierced in its mid-line by the urethral
orifice, — ^the external meatus. The bulbs of the vestibule are two
masses of venous plexuses about an inch long, lying along the
sides of the vestibule below the clitoris and within the nymphae.
They, are the homologues of the corpora spongiosa in the male.
In sexual excitement, by muscular compression of their efferent
vessels, they become turgid and erect.

The clitoris has the structure and anatomical features of the
penis, but in miniature, and modified by the cleft below, the
absence of the urethra, and the separation of the spongy bodies
into the bulbs of the vestibule. The cavernous bodies of the
clitoris are erectile. The glans of the clitoris is surrounded at
its base by sebaceous follicles secreting a smegma, which may be
confined by preputial adhesions, and is likely to cause irritation
by its decomposition.

Bartholin's glands, or the vulvovaginal glands, are muco-
serous, racemose glands about a third of an inch in diameter,
lying under the mucous membrane of the lateral vaginal walls
and emptying by long, slender ducts below the vestibule and to
either side of the vaginal entrance.

The Hymen. — The crescentic septum, occluding usually the
posterior portion of the vaginal entrance, with the concavity of
its of)ening directed upward, but presenting often an annular,
cribriform, cordiform, crenelated, or cleft appearance, is a fold of
mucous membrane reinforced by fibrous tissue, usually ruptured
with ease, but occasionally so firm and unelastic that it even
resists the impact of the descending head in labor. The hymen
is usually torn at the first coitus. scMiietimes by gynecological
examinations, or by masturbation. It is partially destroyed in
labor, the remnants persisting as isolated protuberances around
the vaginal orifice, — the carunculai myrtiformes.

The Vagina. — The vagina is a musculomembranous canal
extending from the hymen to the base of the vaginal portion of
the cervix uteri. The posterior wall of the canal is about 9 cm.
(3.5 in.) long, the anteuior 6.5 cm. (2.5 in.). The axis of the
canal is slightly sigmoid in shape, but corresponds quite closely
to the axis of the pelvic canal. The upper portion of the canal
is expanded into the vaginal vault, the recesses being particu-
larly well marked anteriorly and posteriorly, constituting the
anterior and posterior fornices. The vagina, therefore, is flask-
shaped. The vaginal walls are composed of three structures, —
the mucous membrane, the muscular coat in two layers (the

46 PREGNANCY.

inner circular and the outer longitudinal), and a fibrous sheath.
The anterior and posterior walls should be in contact, while
the lateral walls are thrown into folds which give a transverse
section of the vagina the shape of the letter H. The mucous
membrane is covered with squamous epithelium, and with
numerous papilla, but has no glands except a few tubular
structures in the upper part of the canal. The mucous mem-
brane is thrown into numerous transverse folds or rugae,, most
marked upon the anterior wall and in nulliparous women.
There is an anterior and a posterior cord-like process in the
median line, the anterior and posterior columns of the vagina,
indicating the lines of junction of the ducts of Miiller.

The Uterus. — The uterus is a hollow, muscular organ, in the
adult virgin measuring 7.5 cm. (3 in.) in length, 4 cm. (1.6 in.) in
breadth, and 2.5 cm. (i in.) in its anteroposterior diameter. In
shape the uterus is a flattened, pyriform body, the anterior wall be-
ing almost perfectly flat, the posterior more convex. It is divided
into the body, the isthmus, and the neck, or cervix. The first
occupies about three-fifths of its length, the last, two-fifths. In
structure the uterus consists of a muscular wall with a mucous
lining and a peritoneal covering. The muscle is unstriated and
is arranged, roughly speaking, in three layers, — an external, a
middle, and an internal. The middle layer constitutes the bulk
of the wall ; its fibers arc arranged in a somewhat spiral form,
though no vAy definite arrangement is to be distinguished. The
fibers of the inner and outer layers are arranged in longitudinal
and circular bands. The mucous membrane of the body of the
uterus is composed of columnar, ciliated, epithelial cells, resting
upon a delicate basement membrane. The cilia of the uterine
epithelium lash in the same direction as those of the tubes,
namely, from within outward, or from above downward.^ As
there is no submucous tissue, the muco.sa of the uterus rests di-
rectly upon the muscle. The uterine mucous membrane is
richly supplied with tubular glands, divided in their lower ends
usually into two branches or forks. In the cervix the mucous
membrane is thrown into longitudinal folds with lateral branches,
— the arbor vita: of the uterus. The epithelial cells in the upper
two-thirds of the cer\'ical canal are columnar, ciliated, in the
lower third stratified, scjuamous cells. In addition to the tubu-
lar glands of the uterine bod}' the cervical mucous membrane
contains wide mucous cr\'pts, the orifices of which easily become
obstructed, so that they are converted into retention cysts, which
commonly stud the cervix in cases of old inflanmiation or in-
jury,— the glands or follicles of Naboth.

1 This has lonjj bet-n a (li««iuit( d p«.int. S.t' Mandl. " W-Wx die Richtunj^ dcr
Flimmcrhewegung im nu-nscldulion I'lcrus," "(cntiall.l. f. Ciyn.," No. 13, 1S98.

THE FEMALE SEXUAL UfiaANS.

The uterine cavity is normally rusiform, widened in its upper

part into a triangular space, most contracted below at the level
of the internal os uteri. It has three openings, the interna!
OS communicating with the cervical canal and the two uterine
orifices of the Fallopian tubes. The cervical canal in the nul-
liparous woman is a slender ovoid in shape, contracted al its
upper and lower boundaries. — the internal and the external os
uteri. In a woman who has borne children the cervical canal is
often funnel-shaped, the external os, or the cavity just above it.
being the most expanded portion.

The cervix itself is divided into two portions, the vagina! and
the supravaginal. The former projects into the vaginal vault;

^'Hs^ i\Tr''^\

m^^^

Fig. 37 Section orhuman aCenu. bctnding mucosa [a) and sdjacenl muscular

litsne (i) ; >-, epithelium of (ree surfiLce and tubular uterine gluids [J) : J\ deepest
layer of mucosa, containing fundi of glands ; k, strands of non-atriped muscle pene-
traling wilbin ihc mucosa tHerwl).

the latter is attached to the vaginal walls and extends a short
distance above their attachments. The anatomist commonly
speaks of the supravaginal portion as being entirely above the
vaginal attachments and extending to the isthmus. This view,
however, is erroneous, as it assumes that the lower uterine seg-
ment is a part of the cervix.

It is usual to describe an anterior, shorter lip of the cervix and
a longer posterior one. This description is more accurate in the
parous woman with a bilateral tear of the cervix. As may be
seen in figure 38, the supravaginal portion of the cervix is longer
anteriorly than posteriorly. The normal position of the uterus

PREGNANCY.

is almost horizontal as the woman stands erect. It is slung
between the layers of the broad ligament, supported by lateral,
anterior, and posterior musculofibrous bands and folds of peri-

Fig. 39.' — Ulcnis didelphys : a, Righl segment ; 3, left segment ; (, d, right ovary
*nd round tignmenl : /, r, ted ovary and round ligament ) g, J, left cervix uid va-
gina \ i, vaginal se]iluni ; h, i, right cervix and vagina,

toneutn. It is so freely mobile that it rises and fall-s with every
breath the woman draws.

The uterus is formed by the junction and fusion of the two
ducts of Muller. An arrest of development in embryonal life

THE FEMALE SEXUAL ORGAA'S.

results in a partial junction or a complete failure to unite on the
part of the Miilleriaii ducts. The consequent deformities of the
uterus may occasion 'abnormalities in pregnancy or complications
in labor and after-delivery. If there is complete disjunction of the
two ducts, ths deformity is known as uterus didelphys {Fig. 39).
If there is an outward junction but a complete disassociation of the
two tubes except for their superficial union externally, the condi-
tion is called uterus biconiis duplex (Fig. 40). If there is a junction

a. — litems bicornis duplex ; a, a, Double enlmricE to vagina; /', meatus
c, cliloris; li, utelhra; t, f, double VBgina;/,/, exteniHl oriliccsof ulcnis;

S, X^ double cervis I ll, h, bodic* ami homs of uterus-, (, i, ovoiies : t, t, tubes j

/, /, round ligaments j m, m, broad ligHmtiils.

at the cervix but separation of the ducts above, there is a uterus
bicomis unicnllis {Fig. 4 1 ). There may be complete junction of
the two Miiilerian ducts, but the fusion of the two canals is incom-
plete ; a uterus subseptus or semipartitus is the result. Finally,
one may see in the form of the uterus an indication of its double
origin : there may be a uterus cnrdiformis {Fig. 42) or a uterus
incudiformis (Fig. 43). Occasionally one duct of Mijller de-

PREGNANCY.

velops normally while the other is present as a mere rudiment.
There is, in consequence, a uterus unicornis (Fig. 45).

The vagina is double in uterus didelphys and often in uterus
btcomis duplex. The duplicity of the birth-canal may be con-

fined to the vagina (dmiljlc vagina) or it nia\' affuct the cervix

without involvinj:; the rest of the utcrvis, — uterus biforis (Fig. 44).

The oviducts, or Fallopian tubes, arc tubular structures

about 10 or 12 cm, (3.93 or 4. 5 in.) Inn^, running from the cornua

THE FEMALE SEXUAL ORGANS.

^8- 43- — Uterni iDcudiibcmU.

Kig. 47- — 111 developincnl of lighl iiile al uttnu; coDgiinilal laleral tlcikin.

Fiir 48 —I^ngiludinal sfctioii of Pallopinn tube, expusing the complicaltd loi^fta-
dioal plications of Ihe mucosa *l>icb expand into Ihe timb™ (Sappcy).

THE FEMALE SEXUAL ORGANS.

of the uterus at tlie upper edge and between the layers of
the broad hgament outward, upward, and at their outer extremi-
ties downward and backward to the free surface of the ovary.
The canal of the tube begins in the uterine wal! as a fine
opening {ostium internum) : it expands lo about 2 mm, (0.079 i"-)
in diameter, becomes wider as it runs outward, again contracts
where it passes the ovary, widens again to a distinct opening
4 mm. (o. 157 in.) in diameter (ostium abdominale) into the apex
of the pavlHon, or infundibulum, a funnel-shaped expan.sion at its
outer extremity surrounded by fringed processes, — the fimbriae. ^

The fimbriated extremity is connected with the ovary by the
tubo-ovarian ligament.

The tube has three coats, — a mucous, muscular, and serous.
The mucous membrane of the tubecon.sists of a single layer of
columnar, ciliated, epithelial cells, the cilia lashing toward the
uterine cavity. The membrane is thrown into deep longitudinal
folds, becoming more complex as the fimbriated extremity is
approached. There are no glands in the mucous membrane.
The muscular coat consists of circular fibers of unstriped muscle,

' OMet anatoiniMa divided the lube inlo llie isthmun, comprising llie inner ihiid,
Uie umpulla. Ihe outer or expandcil (Kinioii. ami the fimbriae.

S4 PREGNANCY.

with an outer, ill -developed layer of longitudinal fibers. The
serous covering is continuous with the serous covering of the
broad liganicnt.

The ovaries arc almond-shaped bodies varying in size in differ-
ent individuals and under different circumstances, but having aver-
age diameters of 3.5 cm. (1.38 in.) in length, 2 cm. (0.79 in.) in

F'g- 50- — Section lliniUKli part of ovary of niiuU bilch ; a, Gernunal epiQieljuni '
b. h, ingrowlhs (egg-fubes) from the germinal epilhelium, seen in cross-seciion - ,- i
young titaalian follicles in llie cortical layer ; •/, a more nialure folliclt:, conlaininB
l«o ova (this is rare) ; c anil^ ova surrounded by cells of discus proligerus ; p- ,1
outer and inner capsules of ihc follicle ; /, membrana granulosa ; /, btood-vefsris ■'
m, m, parowarium ; g, germinal epitlieliuiu commencing to grow in and form an egg-
tube; 2, iransilion from peritoneal to germinal epithelium (from Waldeyer).

width, and 1.5 cm, {0,54 in.) in thickness. They are attached to
the posterior layer of the broad ligiimcnt by the hilum. The ovar\-
is a gland secreting eggs. It has, therefore, a gland -structure
stroma, parenchyma, and gland-spaces. There are, however
certain distinctive peculiarities about this gland. Its peritoneal
covering exhibits a modified form of cells, — the germinal epj-

THE FEMALE SEXUAL ORGANS.

thelium. The gland-spaces have no ducts, but excrete their

contents by a rupture of their

walls. The body of the ovaiyis

divided into a cortev and a me

dulla. The former containsthe

gland -spaces called Graafian

follicles (after their discoverer

Regnier de Graaf) set in a

stroma of spindle -shaped con

nective -tissue cells Fhi, ht

ter contain blood vessels

nerves, a few muscle fibers

and irregular groups of pol>

hedral cells (the interstitial

cells), representing atrophic

remains of theWolffian bodies

Besides its connection with

the posterior lajer of the

broad ligament b> the hilum

the ovary is attached to the

uterus by the utero-ovarian

ligament, to the tube by the

tubo-ovarian ligament and to

the pelvic wall by the sus

pensory ligament of the oviry

(ovariopelv ic infundibulupel

vie ligament)

Fig. SI,— Scciioi
eluding coilex : a, Germinal epilheliuia of
free surface; J, tunica albuginea; c, peri-
plierfllhtroraaeontaiiiingimmalure Graafian
follicles / r, Will advanced rollicle from
whose wall Ihe membrana granulosa has
parlially sepanUed f, cavity of liquor
fotliculi g otum surrounded by cell-mass
cotisl luting discus proligerus (riersol).

PREGNANCY.

Menstruation, Orulation, Inseminattoiy and Fertilization} The
Changes in the Ovum After Fertilization.

MENSTRUATION.
Menstruation is the periodic discharge of a sanguineous
fluid from the uterus and the Fallopian tubes occurring during the
time of a woman's sexual activity, from puberty until the meno-
pause. From the earliest ages of medical literature many theories
have been advanced to account for menstruation. The oldest
explanation entertained until comparatively recent times was
founded upon woman's supposed unclean liness. Menstruation
was thought to be an effort on thu part of nature to rid the
woman's body of noxious humors. ' Again, it was explained that
woman was plethoric and that nature provided a periodic vent
for the superfluous blood. In modern times Pflijger has advanced
the theory that menstruation occurs in consequence of a conges-
tion brought about as follows : A Graafian follicle by its growth
finally produces so great a reflex irritation as to determine a local
congestion, which manifests itself in a bloody discharge from the
uterine mucous membrane. Sigismund, l.owenhardt, and Rei-
chert propounded the doctrine that menstruation occurs because
the ovum discharged prior to the menstrual period is not impreg-
nated ; consequently, failing thi.s stimulus to further growth and
development, a retrograde change with bleeding occurs in the
uterine mucous membrane. As a matter of fact, the cause of
menstruation is one of the many life -phenomena at present
beyond human comprehension. All that can be said is that a
nervous influence proceeds periodically from the sympathetic
nerve-glands in the lower abdomen and pelvis, leading to a stimu-
lation and congestion of the sexual organs. We can no more
account for this nervous action than we can explain the nervous
force which continues respiration from the moment of birth until
death. Certain facts from comparative phv.-iioloi^v, however.
throw a glimmer of light upon the subject

' Many poputarsii;>cr<ilitiniisare founded
of mcnslmal hlooil will wiilier a floirer, ai
will turn the milk sour. The mcxlern phi
stilion, if Ihe nulhor niny judge from p*
priety of allowing a menstruatias nnrM i
■bdominal section.

MENSTR UA TION, 5 7

asserted that if sheep fall into heat and are not gratified, the rut
returns in a month. Menstruation in the female is obviously
what rut is in the lower animals, and the bloody discharges from
human females are probably the result of their erect posture and
the pelvic congestion which is a consequence of it.

The mechanism of menstruation is better understood than its
causes. It is a diapedesis of blood through delicate, new-formed
capillaries in a thickened and congested endometrium, the provi-
sion for carrying blood to the membrane being better than that
for bearing it away by the efferent vessels. Leopold has given
the following description of the uterine mucous membrane dur-
ing menstruation :

The mucous membrane is 8 mm. (0.315 in.) thick, swollen,
dark brownish red, soft almost to liquefaction, but perfectly intact
and separated by a sharply defined boundary-line from the paler
muscular tissue of the uterus. The uterine glands, 0.5 to 0.75
mm. (0.0197 to 0.0296 in.) wide, are considerably lengthened
and can be seen by the naked eye. In the superficial portion of
the mucous membrane, which \& very well preserved and only in
certain spots lacks its epithelium and subjacent cells, may be
seen an immense and enormously hypertrophied capillary net-
work, the vessels of which hav^e irregular outlines and lie in the
uppermost layer of the mucous membrane.

From this observation of Leopold's, and from other studies
of mucous membrane removed by the curct during menstrua-
tion, it appears that the theor>^ of hemorrhage in consequence
of degeneration of the mucous membrane is untenable.

There are certain clinical phenomena of menstruation which
must often be taken into account by the obstetrician.

Time of First Occurrence and of Cessation. — The onset
of menstruation is influenced by race, climate, mode of life,
heredity, and genital sense. In temperate climates and in the
home of the Teutonic and Anglo-Saxon races, menstruation
occurs oftener in the fifteenth than in any other year. In these
same races transplanted to the eastern middle sea-board of the
United States, menstruation appears a year or two earlier.

In Hungary the three races, Slavonic, Magyar, and Jew-
ish, living side by side in the same climate, begin to menstru-
ate, respectively, at sixteen, fifteen, and thirteen years of age.
girls of Calcutta and negresses of Jamaica, living in
itic conditions, begin to menstruate at the eleventh
fifteenth year. Climate, however, does influence the
'«»tion. It appears at eighteen years in the girls
vears in Egypt and Sierra Leone.

" a girl determine, to a certain extent,

58 PREGNANCY.

the age at which menstruation begins. If she Hves in a city,
subjected, perhaps, to indiscriminate association with the other
sex and to sexual temptations, the function appears earUer than
it does in the country, or in a girl carefully brought up in com-
parative seclusion. The same rule applies to lower, animals. If
a bull is admitted to the pasture of a herd of heifers, heat
appears earlier in the latter than it would if they were segre-
gated.

It is a matter of common observation that peculiarities of
menstruation run in certain families. Thus, through several gen-
erations of females menstruation appears late and ends early, or
vice versa. By genital sense is meant the strength of sexual
feeling. In women of strong sexual passion the function of
menstruation is commonly instituted earlier and lasts to a greater
age than common. Precocious menstruation is not uncommonly
associated with nymphomania.

Menstrual Molimina. — By this term is meant the local and
reflex subjective symptoms of menstruation. There is a feeling
of weight and heaviness in the pelvic organs, due to their con-
gestion and increase of size. There is a general nei-vous excita-
tion, so that women disposed to hysteria and epilepsy will exhibit
outbreaks at this and perhaps at no other time. The breasts
swell and may secrete milk. The thyroid gland is enlarged and
the tonsils are swollen, so that singers may lose their voice.
There is increased vascular tension, increased activity of the
heart, shown by sphygmographic tracings, and the pulse '\s
accelerated. The temperature is elevated by 0.5° C. The skin
is more vascular and shows unusual pigmentation, especially in
the dark rings under the eyes.

The Character of the FIow.^The discharge consists, in
great part, of blood. It is alkaline in reaction. It contains,
besides blood, mucous secretion from the glands along the
genital canal and epithelial cells. It is dark in color, and should
not clot. It has a peculiar odor from the secretions of the
sebaceous glands at the vaginal outlet, excited, as are all the
structures of the genital canal, to unusual activity.

The Duration of the Flow. — Menstruation rarely lasts less
than three days ; a continuance of four, five, or seven days if
the natural and invariable habit of the individual may indicate
nothing pathological. In the first two or three days the greatest
amount of blood is lost. After that the discharge grows less
until it ceases. A Icukorrhca or mucous discharge for a day or
two after the cessation of the bloo(l\- How is common.

The Quantity of the Flow. — The actual quantity of dis-
charge during nicnstruati(Mi lias been estimated at four to six

OVULATION. 59

ounces. It is not practicable for the physician, however, accurately
to measure the amount of flow. He must estimate it by the
number of napkins worn in twenty-four hours. If a woman is
obliged to change her napkins during the height of the flow
more than three times a day, the quantity of the flow is excessive.

The Cessation of the Flow. — ^The menstrual flow ceases usu-
ally in the forty-fifth year, becoming infrequent and more scanty
over a period of six, nine, or twelve months, until it stops alto-
gether. There are many exceptions, however, to this rule. A
woman who begins to menstruate much later than the fifteenth
year will often have the menopause before forty. Or, if she
begins to menstruate early, she will often continue beyond the
forty-fifth year.

As a rule, therefore, it may be stated that a woman menstru-
ates from about the fourteenth to the forty-fifth year of her age.
Precocious menstruation, however, has been recorded in the
infant of one or two years old, and has continued to the sixty-
fifth and even to the eightieth year.

OVULATION.

By ovulation is meant the discharge of a mature ovum from
its Graafian follicle. The study of the process involves a con-
sideration of the development of the Graafian follicle and its
rupture ; the maturation of the ovum ; the transmigration of the
ovum from the surface of the ovary to the uterine cavity.

The Development of the Graafian Follicle and its Rup-
ture.— The germinal epithelium on the surface of the ovar>'
sends down into the ovarian stroma columnar prolongations
called egg-cords. These cords become constricted at intervals,
so that they are converted into a number of spherical gland-
spaces unconnected with one another and u ithout efferent ducts.
The gland-space is surrounded by a containing membrane (the
theca folliculi) divided into two layers, — the tunica fibrosa and
the tunica propria. The interior of the gland-space is lined with
a layer of epithelial cells, — the membrana granulosa. One of
these cells, more highly specialized than the rest (the ovum), is
surrounded by an aggregation of the cells of the membrana
granulosa, — the proligerous disc. The ca\'ity of the gland-spaces
is distended with fluid (the liquor folliculi) containing paralbumin.
As the Graafian follicle develops, it retires deeper into the interior
of the ovum. Finally, however, the most mature follicle, under
the influence of premenstrual congestion, rapidly secretes liquor
folliculi, swells to the size of a pea or a cherry, so that it stands
out plainly from the surface of the ovary. On the most promi-

PREGNANCY.

nent portion of its free periphery the tunica propria fails at one
spot (the stigma), so that the integrity of the follicle is preserved
only by the tunica fibrosa ; this, too, soon gives way under the
pressure imposed upon it from within, and the follicle ruptures.
The ovum and surrounding discus proligerus, attached to the
follicle-wall just under the stigma, are washed out into the free
peritoneal cavity by the escaping liquor folliculi.

The Maturation of the Ovum — The primordial ovum in
the immature Graafian foUicle is an epithelial cell without a
cell-wall, but with cell-con-
tents called the yolk, a nu-
cleus called the germinal vesi-
cle, and a nucleolus called the
germinal spot. As the ovum
matures, it acquires a cell-wall
with three coats or layers, —
the zona pcllucida, the vitelline
membrane, and the internal
eel I -membrane. The human
ovum is holoblastic, — that is,
it completely segments, — and
contains much more proto-
plasm, or germ-yolk, than
deutoplasm, or food-yolk. In
its maturation, or preparation
for impregnation, the ovum
shows a curious movement of
its nucleus (karj'okinesis, a
moving of the nucleus), which
a|)proaches the cell -periphery,
arranges itself in two star-
sha|x;d figures (the amphiaster
stage), and extrudes portions
of its .substance as little glob-
ules (polar globules) upon the
ifu iii.-;a]ipear and are lost. It is
suppo.-M.Hi that they conlain. (K'rhaps, tlu- male suKstanoes, which
miglit unite with tin- fiiii.tle porlions of tlie o\ inu to produce an
imtK'rfect Ix-ing, as is done in ivitain liemiapliroditic animals.
Nature, it is prvsiniKd, l.ikts this nuMSun' to prevtnl partheno-

inlmvding- -\ Mniilar action may

.■.in dmiii-^ iis .lc\ .lopmeni. After
>'|.ui,s the nii,K-us relro.ils into the
onu -^ tJK- rem. ill- pronucleus. The
■ation.

£iif ~~k

Fig. 5J. — Section (hr»ugh psrt or a
nuunmalion ovtrr : A'£, (it<niiliiiil cjiiilu'li
um; /'.ViUiece-ciiid; V, L\\v\xa\Kn\: o\a\
G, investing cells j A', |>rniiiiinl vesitli-;
.S', rolliculor cavitv nrisini; in <>iif af tlic
older follicles ; Lf. f.-lliculnr <'avily. inxT.'
eniBn:«l; A'/, nearly nialurc ovum, uhii-li
hu drvt<lu|ieil ariHinil it (hu lona prllu-
cidt, Mp : Mg. nii'iul>raiia cranuUiso; 7'.
PisCUi pniliBvrus; .■>;•, iivarinii sinima;
Tl\ mpsule of follU-lo ; i'. v. ^U.-.l.vrs■.fl^ ;
H, inimamre <.;™alUii fol'lUI.- (iifi.T Wir.

ovular suri'ace. Tlu-.s.> globnU-s t

ecIos.sl kill

genesis, or ll'
be ob.ser\ed in llu- s]
the extrusion of tlu-
interior of liie o\ imi
ovimi is now reaii\- V

orVLATION.

The Dischargeof the Ovum from theOvaryand its Migra-
tion to the Uterine Cavity. — Ova are discharged from tlie ovarj-
from pubtrty until ihc menopause, — that is to say, on the average,
from the fourteenth to the forty-fifth year. Ovulation, however,

F^E' S4'— Fonnalion of polar bodies in ova of Aslrrias glaeialis : fij, PoUr

j)iiiia]e ; pb', firsl polar body; fb'', second polar body; n, nucleus reluming lo
condition of resi (Herlwig).

may begin before menstruation, may cease before the menopause,
or possibly may continue after it. A young girl has been im-
pregnated as early as the ninth year. In the child -marriages of

India impregnation has occurred before menstruation had begun ;
but usually premature maternity is preceded by precocious men-
struation. Ovulation has continued, as proved by impregnation,
until the fifty-second, fifty-fourth, fifty-eighth, and even to the six-

62 PREGNANCY.

tieth year ! A case is recorded of delivery at the age of fifty-nine
years and five months. An obstetrician investigating the nature of
an abdominal tumor should remember, therefore, that pregnancy
is possible from the ninth to the sixtieth year. After the ovum
is discharged from the ovary it is caught in a current of fluid
moistening the surface of the ovary, and is carried to the interior
of the corresponding tube. The existence of this current of fluid
is explained by the movement of the ciliated epithelium in the
tubes. In some animals there is a development of ciliated epi-
thelium on the peritoneum at the time of ovulation. Arrived in
the tube, the ovum is transported to the uterine cavity by the
movement of the cilia on the epithelium and by the vermiform
movements of the tubal walls. In certain cases of extra-uterine
pregnancy an anomalous transmigration of the ovum has been
demonstrated. Thus it is possible for the ovum, after its dis-
charge from the ovary, to be taken up by the fimbriated extremity
of the opposite tube, — an external transmigration of the ovum. It
is also possible for the ovum to traverse one tube and the uterine
cavity and to enter the uterine ostium of the opposite tube, — an
internal transmigration of the ovum.

It has been calculated that the human ovary at birth contains
70,000 ova. As it is unlikely that any woman discharges many
more than 360 ova, even if she ovulates "uninterruptedly for thirty
years, an enormous number of ova must atrophy, disintegrate,
and disappear within the ovary.

THE CORPUS LUTEUM.

The changes which occur in the Graafian follicle after its rup-
ture and the discharge of the ovum, discus proligerus, and liquor
folliculi lead to a formation within the Graafian follicle called the
corpus luteum.

There is an effusion of blood into the cavity of the follicle and
an enormous development of the membrana granulosa. Leopold
thus describes the development of the typical corpus luteum : It
appears on the first day as a follicle just broken open, the inte-
rior filled with blood. From the eighth day on there appears a
fine capsule around the blood-extravasation, while the inner por-
tion becomes lighter and clearer. From the twelfth day the
capsule grows thicker and is thrown into folds ; from the six-
teenth day it becomes a pale red, merging into a yellow. About
the twentieth day the central matter of the broken follicle has
become much shrunken, while the capsule, more decidedly a pale
yellow, projects toward the center of the follicle in rays and
narrow folds. "^^ '^um of menstruation, or the so-

OVULATION AND MENSTRUATION. 63

called false corpus luteum, reaches its highest development in
ten to thirty days. Nine days later it is merely a lamina of
fibrous tissue beneath a little pit or depression of the ovarian
surface. The true corpus luteum of pregnancy, so called, is
simply an exaggeration of the corpus luteum of menstruation, the
longer growth and greater size being due to the stimulation and
congestion of gestation. It grows for thirty or forty days afler
conception, occupying a third, perhaps, of the ovarian area. It
then remains stationary until after the fourth month, when it begins
to atrophy ; at term it is only two-thirds its largest size ; one
month later it is reduced to a small mass of fibrous tissue. The
true corpus luteum is of value as an indication of the ovary from
which the impregnated ovule came. It should be remembered,
however, that the ovaries of virgins have exhibited corpora lutea
like those of pregnancy in consequence of intense and prolonged
congestion.

THE CONNECTION BETWEEN OVULATION AND

MENSTRUATION*

Neither one of these functions is dependent upon the other,
but they both depend upon a common cause, — the periodic
nervous excitation and congestion due to an impulse from the
sympathetic nervous system. Dependent as they are upon the
same cause, their occurrence is usually synchronous, — that is,
the ovule is discharged at the height of menstrual congestion.
But this is by no means the invariable rule. Leopold,^ in an
examination of twenty-nine pairs of ovaries removed on suc-
cessive days up to the thirty-fifth after a menstrual period, found
a Graafian follicle bursting on the eighth, twelfth, fifteenth,
sixteenth, eighteenth, twentieth, and thirty-fifth day after the
menstrual period. In other words, ovulation may occur without
menstruation at any time in the intermenstrual interval. In five
cases there was no ovulation at the menstrual period, or men-
struation occurred without ovulation. Many examples might be
given, from clinical observation, of the mutual independence of
these two functions. The common occurrence of impregnation
during lactation is a good instance of ovulation without men-
struation. ^ Menstruation after oophorectomy and during the

1 "Archiv f. Gyn.," Bd. xxix, S. 347.

* Remfry (** Revue Internationale de Medicine et de la Chirurgie," 1896, No. 5)
has found by an investip^ation amonp; 900 nursing women that in 57 per cent, only
did there occur an absolute amenorrhea. Menstruation was regular in 20 per cent.
and irregular in 43 per cent. It was also common for conception to occur during
lactation, 60 per cent, of the menstruating women conceiving. Among the non-
menstruating women but 6 per cent, conceived during lactation.

64 PREGNANCY,

first three months of pregnancy occurs without ovulation. I
attended, in her first childbirth, a young woman twenty -two years
old, who had never menstruated. She had obviously, however,
ovulated. Repeated ovulation without menstruation is seen
also in those curious cases of postmarital amenorrhea, lasting
for years. The wife of a physician among my acquaintances
menstruated once after marriage ; in the following fifteen years
she bore ten children without ever menstruating. Three years
after the birth of the last child, or eighteen years since its cessa-
tion, menstruation returned copiously and regularly, but more
frequently than normal, for twelve years. The menopause then
began, at the age of forty-eight. ^

Finally, I was once obliged to remove the ovaries in a case
of ill-developed, infantile womb, associated with well -developed
ovaries, in which there was a violent exaggeration of the men-
strual molimina every month without a discharge of blood and
the consequent relief of menstrual congestion. The ovaries
were found, after their removal, to be filled with well -developed
Graafian follicles and numerous depressions representing corpora
lutea. In one of these ovaries there was a corpus luteum that
would have answered for an illustration of the yellow body of
pregnancy.

INSEMINATION.

By the term insemination is meant the ejaculation of seminal
fluid from the male organ and its deposition within the genital
canal of the female. The studv of insemination involves a con-
sideration of the seminal fluid, the development and life-history
of its active constituent (the spermatozoa), the mechanism of its
ejaculation from the penis, and of its reception within the vagina
and womb.

The seminal fluid is vellowish white in color, thick and
sticky in consistency, varying in quantit}' at each emission from
one-quarter to two drams. It possesses a peculiar odor and is
neutral or alkaline in its reaction. The constituent parts, on
chemical examination, are found to be water, eighty-two percent. ;
salts, mainly phosphates ; protein matter, fats, and spermatin.
On microscopical examination there are seen seminal cells, cr}'S-
tals of phosphates, and sprrfUiUtKOii, discovered by Hammen in
1677 and demonstrated to be the active principle in fertilization
by the filtration experiments of Spallanzani and others. A sper-
matozoon is 3-J^^ of an inch in length and possesses a power of

* Similar cases ure reported in "Amer. Jour, of Obstetrics," 1892, p. 352, and

INSEMINA TION.

motion by which it can travel with a rapidity variously estimated :
its own length in a second, one inch in seven and one-half minutes
(Henle), or from the hymen to the neck of the womb in three hours
(Marion Sims). Their progressive force is sufficient to overcome
obstacles that appear insuperable ; they may be seen, under the
microscope, to push aside epithelial cells ten times their size.
Their vitality under favorable circumstances is remarkable. They
have been found alive in the testicles of criminals who had been
executed three days, and of bulls which had been killed six days
before. In the cow they have been found six
days after insemination, in a rabbit, eight days ;
in the female bat they may be found alive for
months, and in the queen-bee for three years.
In the human female living spermatic particles
have been found in the cervical canal eight
days after copulation. On the contrar)- , they
are extremely susceptible to certain unfavor-
able surroundings. They are destroyed by
heat, cold, acid solutions, lack of water, and
the mineral poisons. A solution of bichlorid
of mercury, i : 10,000, is fatal to them. As a
consequence of chronic disease in the man, of
alcoholic or sexual excess, or of catarrh of
the seminal vesicles, the spermatozoa may be
dead when emitted. As a result of inflam-
mation and obliteration of the seminal ducts
or of anatomical defects the seminal particles
may be absent from the seminal fluid.

The indifferent constituent parts of the
seminal fluid are derived from Cowper's glands,
the prostate, and the vesicular scminales. The
spermatozoa are developed from mother-cells,
or spermatoblasts, specialized from the epithe-
lium of the testicle. In the course of their
development a portion of the cell is extruded
(seminal granule or accessory corpuscle) just
as in the maturation of the ovum the polar globules are cast off.
In the fully developed spermatozoon the head represents the
nucleus of an epithelial cell, and the tail cell-contents specialized
in the form of a cilium, with much larger size and greater power,
however, than the cilia of ordinary ciliated epithelium possess.

Spermatic particles first appear in the seminal fluid at about
the fifteenth or sixteenth year. There is often, in boys of twelve
or thirteen, a seminal discharge, but it contains, as a rule, no
spermatic particles. I have had charge, however, of a girl four-

Fig. 56. — Hu-
man s))€rmatozoa : Ay
Spermatozoon seen en
face; hy head ; w,
middle-piece ; /, tail ;
ey end-piece; B^ C,
seen from the side
(after Retzius).

PREGNANCY.

teen years of age impregnated by her brother, aged thirteen, who
had stimulated his sexual development by masturbation. Sper-
matozoa often disappear from the sexual discharge of old men,
but the age at which this disappearance occurs varies greatly.
As a general rule it might be put down as sixty-five, but it will
be remembered that the French engineer, de Lesseps, was a
father at eightj'-two, and that old Thomas Parr illegitimately
impregnated a woman after he had passed his hundredth birth-
day.

Fig. 57. — a-h, Isolal.ii !.piTiii tells of llii; ral. slifttiiiy ibt- ilevelopmeTH of the
ipcnoaioioon and the gradual iraiisfiTiii.nion of llie nucleus inw the spenoaloioon
head. In g, (he semiiijl (iranule is bting cast i.lV (after H. H. Brawn), i-w,
S|>enn-celU of an ela:im<ibr;iiith ; ihe uutli-iu of i-ath cell divides inlo a Ijr^i^ iiuniber
of daughter -nuclei, each cf ttliieh liecomet ciniTerteil inl>>tlie rinl-shajieil head of &
spetraaloioon (jftrr Seni(vri. m. Transverse seclii-n of a ti]* cell, sliowing the
bundle of S[iennaio/oa and ilie [lassive nuiteus (■',«. after Sniper', o-s, S|)enna.
li^enesis in the eaithworni ; i\ y-'ung j(>onu fill ; ,-, ilie same divid.il inlo four ;
jF, spennjtophore with l!ie eemt.d s(icrni lila-ii>[ili. if ; '. a l.i[ir >lagc ; J, neatly
mature spermak'ioa (after |il,miUldl (fn'Hi H addon .

The Mechanism of the Ejaculation of Seminal Fluid and
of its Reception within the Genital Canal of the Female.

— The mechanism of ejaculation is oiil\- undiTstood by a study
of the anatomy of the penis, which mvd not Ix.' considered here.
It is sufficient to state that at the height of the orgasm in the
male the sero™"' ^ « emitted by the action of the circular
and .' of the vesicui.e seminales and of

INSEMINA TION, 67

the urethra. The mechanism of the reception of the fluid within
the genital canal of the female is a much more important matter
to the obstetrician, for on a knowledge of this subject depends
the comprehension of many a case of conception and of sterility.

It has been found, in studying tlie sexual congress of animals,
especially in horses, that during the emission of semen and for a
short time afterward the uterus exerted an intermittent suction,
or aspiration action, upon the seminal fluid, drawing it into the
uterus. In the observation of sexual excitement in bitches it
has been noticed that the uterus is drawn down into the small
pelvis. In experimenting with the electrical stimulation of the
sexual organs in female animals, it was observed that the uterus
grew shorter, but broader ; that it descended toward the vaginal
outlet ; that the cervix projected farther than normal into the
vaginal canal, at the same time becoming softer and shorter, but
broader, by which action the os uteri was opened. The stimulus
being removed, the uterus returned to its normal condition and
the OS closed.

These interesting experiments upon animals have been con-
firmed by observations which gynecologists occasionally have
the opportunity of making upon erotic females during a specular
examination. It is justifiable, therefore, to state that in the
orgasm a woman*s uterus becomes broader and shorter ; that it
descends into the small pelvis ; that the cervix projects into the
vagina, becomes broader, shorter, and softer, and that the os
opens ; these actions being intermittent, the uterus might be
likened to an animal gasping for breath. It would appear that
the intention of this action is to suck the seminal fluid directly
into the uterine cavity. The postmortem examination of two
women murdered at the conclusion of a copulation in whom the
uterine cavity was found full of seminal fluid does not, therefore,
seem necessarily apocryphal, though the reports date from an
unscientific age, and have been used as the foundation of absurd
theories. ^

A perfectly normal and typical mechanism of the reception of
seminal fluid may be thus briefly described : The orgasm of male
and female should be synchronous ; as the seminal fluid is ejacu-
lated from the penis it is sucked in part into the uterine cavity.
An absolutely normal mechanism, however, is not always neces-
sary to impregnation, though a lack of it explains some cases of
sterility. One of my patients bore a child within a year after
marriage and then remained sterile for six years. During the
whole of this time she did not once experience sexual excite-

* See Janke, ** Hervorbringung des Geschlechts," Berlin and I^ipsic, 1887.

68 PREGNANCY.

ment during intercourse. Finally, for the first time in six years
there was an orgasm, and it was synchronous with the husband's.
This coitus proved fruitful. The resultant pregnancy, curiously
enough, was tubal. There are many women who have abso-
lutely no sexual feeling and who never experience an orgasm,
but who, nevertheless, become pregnant repeatedly. Insemination
has occurred also when the woman was asleep, drunk, asphyx-
iated, or unconscious from some other cause. These cases are
explained by the deposition of semen in the vault of the vagina,
in what is called the seminal lake, into which the cervix projects.
The spermatozoa, attracted by the alkalinity of the cervical
mucus and repelled by the acidity of the vaginal secretions,
make their way through the cervical canal into the uterus. This
explanation presupposes a normal position of the uterus, but a
retroverted uterus, with the cervix tilted so far forward that it is
not bathed in the seminal lake, is not necessarily a bar to con-
ception. The motility of the spermatozoa enables them to pene-
trate the canal, although it may be difficult of access. Retro-
version, however, is sometimes a cause of sterility. One of my
patients bore a child and was sterile for five years afterward.
On examining her to learn the possible cause of her sterility,
which she had desired to remedy if possible, I found a complete
retroversion. The malposition was corrected and the uterus was
supported with a pessary. In the next six years that woman
bore five children. The motility of the spermatozoa accounts,
too, for the cases of conception without insemination at all, —
that is, after a mere dej)osition of seminal fluid upon the external
genitals. I have attended in confinement two married women
with unruptured hymens, and on one occasion examined a young,
unmarried girl with a perfectly intact, though delicate hymen,
who had been impregnated, during an embrace by her lover in the
erect posture, from the deposition of semen upon the labia
majora.

The Meeting Place of Ovule and Spermatic Particle. — It
is generally assumed that the spermatozoa meet the ovule in the
ampulla of the tube. That this may be the meeting place is
proved by cases of tubal pregnancy. There are strong argu-
ments, however, in favor of the fundus uteri as the normal
meeting place of spermatic particle and ovule. If ovulation
occurs at the height of menstrual congestion, the ovule has
probably reached the uterine cavity before the fruitful coitus
occurs. Hyrtl ^ found llie ovule in the uterine extremity of the
tube in a girl who had died on the fourth day of menstruation.

» MUller's ** Handhuch," vol. i, p. 151.

S^menlsdon : 1, a, 3, Diagnims il!u5lr«(iii(j Ihe segnj eolation of tlic mnmmalian
ovinn (ADen Thompson, after von I(»iici)cn) ; 4, diagmin illusimling tbe rclalion of the
pnai«i7 layets of ibc hlasloderm tBonnel).

INSEMINATIONS. 69

In Jewesses, who are proverbially prolific, copulation is not
allowed until a week after the cessation of menstruation. It is
almost inconceivable that the ovum has not reached the uterine
cavity by this time. The question, however, is not yet decided,
and the student is at liberty to adopt the view most acceptable
to his reason.

The Fertilization of the Ovum. — From what has been seen
in the lower animals and in the vegetable kingdom, it is probable
that the ovum, during its passage through the tube or on its arrival
in the uterine cavity, excretes some material which attracts the
spermatic particles, as the female elements of some plants attract
the male elements by an excretion of malic acid. From the
swarm of spermatozoa around it a number may penetrate the
cell-wall of the ovum, but only one penetrates the cell-contents.

F R 5I — Port n of ihe ova of Asltrias fflacialis, showing the approach and
fus on of the spcimaroB on with Ihe ovum ; a, KertiliziiiK male element ; *. elevation
of protoplasm of ecg; A', i'', stages of fusion of the head of Ihe spermatoiofln with
Uie ovum (Hertwig).

The head of this spermatozoon fuses with a projection from the
protoplasm of the ovum ; the tail disappears. The head then
penetrates the cell-contents and becomes the male pronucleus, —
a small, oval body with a striated arrangement of cell-contents
about it. Finally, the male pronucleus unites with the female
pronucleus. Conception occurs at the moment of this union, and
from this instant dates the life-beginninfj of the future embryo,
fetus, and infant.

The Time when Coitus is Most Likely to Result in Con-
ception.— Statistical studies show that impregnation is most
likely to occur after copulation during the first eight days suc-
ceeding the cessation of menstruation. There is a period, begin-
ning fourteen days after the cessation of men.struation and lasting
for a week, during which coitus is least likely to be followed by

PREGNANCY.

conception. Some regular women among my patients avoid
iniprc};nation or become pregnant at will, by following or disre-
gartiing this rule. As any woman, however, may ovulate at any
time during the intermenstrual period, this method of pre\'enting
conception is by no means invariably reliable.

i, Brc amiroiioliiiif; ; In .., ...»,, ...„■. «
'etiuii of r<:rlllizaliuii ; i.«., seginijiilat

iJetiui

.nd the female pronucleus,

■;,,-' ■•'!'™ "• echmus after ct«a-
IHerlwig).

The Average Date of Conception alter Marriage Nor-
mally, impregnation should succeed the first menstruation
following marriage, but marriages are only called sterile after
eighteen months have elapsed without conception. Pregnancy
is possible, however, after years of sterility. I have had under
my care women who conceived for the first time nine, thirteen
and twenty-four years after marriage.

INSEMINA TION.

i="

"^1*:

-41'

:-i;

;^i;

nrrr

TT-l

■^

—

■;H:

—

■ : |-F ■

—

~- i

—

\/^

■ — 1

L—

Figs. 6oanil()l. — (.' urvesshowingrelaliTe frequency of conception followingcoilus
■t differenl times in letalion in mcn^tlniation. In both diagrams the divisions on (he
■l»cissa line corresiiunil lo days : in the tint, to days after tlie onset of menstnialion ;
In the aecond, lo days iiflw Hie couwiion <if mensiroation. The curves indicate the
pTopoition of GOnce|ilions lo ropulatiuns on each day of the menstrual month (IlenKn).

P/^ EG NANCY.

Fig. 62.. — Diagrnminatii
of a m&mmalian lilosKxlcnii oflur llie
corer-cells have completely closed in
the blastoderm, and ibc embryo pro[)er
has become two-] ayured: tp', Non-eni-
brjonic epiblaat; i^p, embryonic epl-
blast; Ay, hyjiobl^t ; ys, yolk-sac
(from Hsddon).

CHANGES IN THE OVUM FOLLOWING IMPREGNATION.'

Directly after the formation of the nucleus of segmentation by

the fusion of niale and female pronucleus the ovum begins to
segment. The original mass di-
vides itself into two celts (blasto-
mercs), these into four, and so on
until the whole ovum is sur-
rounded by a layer of cells inclos-
ing a group of somewhat larger
cells (morula, or mulberry mass).
and a hollow cavity containing
albuminous fluid. This stage of
development is called the blastula,
or blastodermic vesicle. The cells
of tiie ovum next arrange them-
selves into a thinned-out, lami-
nated layer around the periphery
of the ovum, and another layer
just within this, the offspring of

the central mass of cells (the ectoderm), and the proliferating

central mass itself, — the

entoderm. Regarding the

surface of the ovum, an

oval, opaque region may

be observed (the embryonal

area), and in the middle of

this area a streak of greater

opacity appears. — the prim-
itive streak. At the site <. •(

this streak a depression

next appears, — the prim-
itive groove. A microscojiK

examination of a sectinn

through this region nun

shows the development of

a median layer of cells (the

mesoderm), made up of

cells derived in part from a

layer furnished by the ecto-
derm and by another fur-

■ It ii not iiilended lo give more than a mere sketch of the development of the
embiTO. The 5imJenl inlercsled in the subject is referred to special works, such a*
MinDt'i"Embi7ol(^."

Fig. G3.- Liiibrjuiik area of rabbit ei
htya : Primilive streak beeinning in ce
prolifcrnlion, known as the " node of Hensei
(E. V. Ikneden].

CHANGES /.V OVVM i-OLLOiVlXG IMFKEGXATION.

nished by the entoderm. In the course of its development the
mesoderm develops lateral reduplications and parts into two layers
(the parietal and visceral layers) inclosing spaces, — the body-
cavity, or celom ( Fijj. 64). The parietal or somatic layer unites
with the ectoderm to form the somatopleure. The visceral or
splanchnic layer joins the entoderm to form the splanch-

Fig. 65.

UUint vt
nd- a- half- day sheep embryo (Bonnel).

nopleure. At the end of the second week the development of
the embryo proper begins, by the formation of the neural folds.
the neural canal, the chorda dorsalis, or notochord, and the
somites, or provertebr.-e. The normal development of the em-
bryonal body now depends, in its gross features, upon an arch-
ing-over process of cells which inclose the spinal canal, the

74 PREGNANCY,

abdominal and thoracic cavities, and the cranial cavity. An
arrest in these developmental processes results in such deformi-
ties as spina bifida, exomphalos, celosoma, hydrencephaloccle,
and anencephalia.

CHAPTER 111.
The Development of the Embryo and Fetus*

TnK chani;cs in the developing embryo and fetus^ that mark-
its L^rowth frommonth to month have practical value for the ob-
stctricicin wlicn he would determine the probable date of im-
prcL^niation from the appearance of the cast-oflT ovum. The
intelligent ex[)lanati()n of many congenital deformities and intra-
uterine accidents and diseases also depends upon a knowled^^e
of intra-uterine development.

First Month. — Fhe life-history of the human ovum durim''
the early [)art of the fust month is involved in considerable
doubt. The place in which the spermatic particle and ovule
meet, the leni^^th of time required for the passage of the latter
from the ovary to the uterine cavity, the part that the linin<^
membrane of the oviduct and its secretion plays \\\ the nourish-
ment of the ovule and in the production of certain modifications
in the external coat are all matters yet in dispute ; and as direct
observation of the human ovum during and shortly after impree-
nation fails us, we must base our theories as to the site in which
this phenomenon (occurs, as to the changes that immediately suc-
ceed it, upon what has been actually seen to occur in the lower
animals, and upon the clinical history of those pregnancies in
which the ovum is developed in an unnatural situation. Thus it
is argued that the spermatic particle mu.st penetrate the ovule
shortly after its escape from the Graafian follicle, for the occa-
sional occurrence of abdominal and tubal pregnancies proves
that the so-called spermatozoa can make their way far into the
tube and even on to the surface of the ovary ; and what is seen
in animals, makes it probable at least that the outer coatine of
the ovule, during its passage through the tube, receives an addi-
tional thickness from an albuminous deposit upon it, or that the
original cell-wall becomes denser and more tough by a process
of coagulation ; either of which conditions would render the
penetration of the ovule by the spermatic particle unlikely, if not

* The usual plan of calling the p/oduct of conception ** embryo " for the first
three months, and afterward "fetus," is the one adopted here.

DEVELOPMENT OF THE EMBRYO AND FETUS. 75

76 PREGNANCY,

impossible. On the other hand, it is claimed^ that if the ovule
escapes from the ovary at the beginning of the menstrual flow,
and if the fruitful coition occurs only some days after menstruation
has ceased, as is common at least among civilized people, the time
that intervenes between the rupture of the Graafian follicle and
the deposition of semen in the female genital tract has been too
great to lend probability to the idea that the ovule still remains
in the ovarian extremity of the oviduct, but, on the contrary,
would insure its presence in the uterine cavity. It is asserted
that the rhythmical contraction of the muscles in the tubal walls
which tend to drive the exuded menstrual blood, as well as the
ovule, toward the uterus would offer an additional barrier to the
ascent of the spermatozoids. This argument is invalidated,
however, by the occasional occurrence of extra-uterine preg-
nancy. There has been great difference of opinion in the past as to
the manner in which the ovule travelled from the Graafian follicle,
after its rupture, to the orifice of the oviduct, the usual explana-
tion having been that the fimbriated extremity of the latter
became "erected" at the time the ovule escaped, and grasped
with its fimbriae the surface of the ovary, thus displaying a sort
of independent intelligence. As, however, the anatomical impos-
sibility of the fimbriae being closely and accurately applied to the
surface of the ovary has been demonstrated, ^ and as the tube
contains no true erectile tissue, this theory has long been ex-
ploded. The fact that the fimbriae are provided with ciliated epi-
thelial cells which work actively toward the uterus, and create a
stream in the moisture which is always present upon the peritoneal
surface, is now held sufficient to account for the transference of
the ovule from the ovary to the oviduct. The ovule, being dis-
charged from the Graafian follicle, is either brought directly
in contact with the cilia of a fimbria, or else, dropping upon the
peritoneum, it is caught in the gentle current of a minute quan-
tity of fluid that always bathes that membrane, and is so conveyed
to the wide opening of the abdominal end of the oviduct. This
explanation will also account for the so-called " external migra-
tion " of the ovule, which, discharged from an ovary and failing
for some reason to be taken up by the corresponding tube, finds
its way to the opposite tube, — an occurrence that has been
observed in certain cases of tubal pregnancy.^

' See Wydcr: ** Beitr. ziir T.ehre v. d. Extrauterinschwangerschaft u. dem Orte
des ZusammentrefTens von Ovuliim u. Spcrmatozoen," "Archiv f. Gyn.," Bd. xxviii,
S. 325.

a Henle, «*IIandb. d. Anat. d. Mcnschen," 1864, P-* « «^ A70 ; andBischoff,
" Entwickclungsgeschicte," S. 28.

• Wyder, he, cit.

DEVELOPMENT OF THE EMBRYO AND FETUS. 7 J

The changes in the ovum immediately before impregnation are
described in the preceding chapter. The changes in the uterine
mucous membrane preparatory to and after the lodgment of the
ovum in one of the depressions formed by the folds into which the
hypertrophied mucous membrane is thrown will be described fur-
ther on. It only remains to notice the successive changes in size
and development that would enable one to determine the length
of time that had elapsed since impregnation occurred, and to
comprehend more fully intra-uterine deformities and diseases.

The youngest human ova seen and described have been eight
to thirteen days old. ^ The embryo is 2 mm. (0.079 ^"0 long, the
chorion is furnished with thin and simple villi, the allantois is
not to be detected, and almost the whole ovum is occupied by
the yolk-sac.

Waldeycr has described an ovum, twenty -eight to thirty days
old, that measured 19 mm. (0.748 in.) in length, 16.5 mm. (0.649
in.) in breadth (about the size of a pigeon's ^gg), and weighed
2.3 gm. (36 grs.). The length of the embryo, in a straight line
from cephalic to caudal extremity, was 8 mm. (0.315 in.), while
the actual length of the dorsal line was 20 mm. (0.79 in.).

During the first month the human embryo is indistinguish-
able from that of other mammals. The ovum at this early
period may be described as a double-walled, flattened vesicle,
filled with fluid. The outer wall bears the branched villi ; the
inner one is smooth. The connection of the villi with the
decidua reflexa, and even with the dccidua scrotina, is a super-
ficial one, and the ovum is easily separated from its uterine
attachments. 2 The yolk-sac, at first occupying nearly the
whole ovum, even at the end of the first month is larger than
the cephalic extremity of the embryo. The visceral arches are
distinct ; the limbs are merely rudimentary^ ; the cord is straight,
thick, and short ; and the amnion is still quite close to the
embryo, and is separated from the chorion by a clear space.

As to the embryo itself, during the first month the heart ap-
I>ears as a cylindrical body, which soon becomes S-shaped, and
by the fourth week displays four distinct cavities and is covered
by its pericardium. It is probably functionally active by the
third week. ^ The brain and spinal columns are inclosed ; the

1 " Edinb. Med. Jour.," vol. Hi ; ** Verhandl. d. Ak. d W. Amsterdam," iii, 3 ;
"Historic du Develop.," pi. iii; "Arch. f. (Wn.." Bd. v, S. 170; **Al)handl. d.
KSnigl. Ak. d. W. zu Berlin"; " Wien. med. Wochen.." 1877. S. 502; "Arch.
f. Gyn.," Bd. xii. S. 421 ; ibiii , Bd. xii, S. 482 ; Leopold, " Centralbl. f. Gyn.,"
1896, p. 1057 ; also ** Uterus u. Kind. "

• See Br. Hicks, **Obst. Tr.." xiv, p. 149; Langhans, "Archiv f. An. u.
Phys.." 1877, ii u. iii, S 231 : Ahlfeld, "Arch. f. Gyn.." Bd. xiii, S. 231.

• Pireyer, ** Specielle Physiologic des Embryos."

/S PREGNANCY.

intestinal tract is also closed over, but the connection with the
umbilical vesicle is still a wide one ; the first traces of a liver
appear ; the primitive kidneys may be seen ; and toward the end
of this period the eyes may be distinguished at the sides of the
head and the rudimentary extremities become visible as four bud-
like processes. The oral and anal orifices of the intestinal tract
are foniied by depressions in the integuments, which (Jpeii into the
extremities of the tract after the absorption and disappearance of
the intervening; tissues.

Second Month. — At the beginning of the second month the
ovum is the size of a pigeon's egg, and the embryo measures
8 mm. (0.3 inch) in a
straight line from head to
tail. During this month
the embryo grows to 2. 5
cm. { I in.) in length and
the ovum reaches the
size of a hen's egg. The
vi.sceral clefts close, with
the exception of the first,
which eventually forms
the external auditory
niratus, the cavity of the
t) mpanum, and the Eu-
stachian tube. The first
visceral arch, dividing
into two branches, forms
the superior and inferior
maxillary processes.
The latter, one from
each side, approach each
other and finally unite
to form the lower jaw.
The superior maxil-
lary processes, while ap-
proaching each other, are kept from uniting by the interven-
tion of the frontal process. At the point of junction of this
last process with the two superior maxillary processes there
occurs occasionally the deformity known as harelip, from the
failure of the processes to unite ; but as union is always perfect
before the end of the second month, the arrest of development
that results in this deformity miiM '■ '■ ' ■ :il.ii-r'

period prior to the third month.
from the growth of the viscera, 1 1 1
straightened out, and from the ■

» (Hi,).

DEVELOPMENT OF THE EMBRYO AND FETUS, Jg

head increases in size. The umbilical vesicle atrophies, and
may be found attached to the body by a slender pedicle. The
umbilical ring is somewhat contracted, but still contains a few
loops of intestine ; so that if at this time an arrest in the devel-
opment of the abdominal walls should occur, a bad umbilical
hernia or exomphalos might be the result. The umbilical cord
runs straight to the periphery of the ovum. The eyes occupy a
position on the side of the head ; behind them may be seen the
ears, and in front arises the external nose. The limbs are sepa-
rated into their three divisions, and the first suggestions of hands
and feet appear, with the fingers and toes webbed. The Wolffian
bodies are much lessened in size, but the kidneys and suprarenal
capsules are now developed. The external genitals make their
appearance, but neither internally nor externally is the sex to be
distinguished, for the elements of both sexes are present in equal
degree. Toward the end of the second month or at the begin-
ning of the third the eyelids appear. There are points of ossifi-
cation to be seen in the lower jaw and clavicle. The villi of the
chorion have taken on a more luxurious growth at the point
where the future placenta is to be developed, and the fetus is
drawing its nourishment from the maternal blood.

Third Month. — During this month the ovum attains the size
of a goose's ^gg, 9.5 to 11 cm. (3.74 to 4.3 in.) long, and the
embryo grows to a length of 7 to 9 cm. (2.75 to 3.5 in.) and
weighs about 30 gm. (460 grs.). The umbilical cord increases in
length to 7 cm. (2.7 in.) and becomes twisted. The umbilical ring
is smaller and the intestines are retracted within the abdomen.
The fingers and toes lose their webbed appearance, and the nails
appear as fine membranes. The eyes approach nearer to each
other and become protected by the lids. Points of ossifica-
tion may be found in most of the bones, and the neck now
separates the head from the trunk. The ribs divide the trunk
plainly into chest and abdomen ; the oral and nasal cavities are
separated by the palate ; the lips close over the mouth and teeth
begin to form in the jaws. The sex may be distinguished by
the presence or absence of a uterus ; cutaneous folds form a
scrotum or the labia majora, but the clitoris and penis are still of
equal length. The chorion loses its villi, except at the point
where the placenta is developing. The latter, though small,
can plainly be distinguished.

Fourth Month. — In the fourth month the fetus attains a
«^ 10 to 17 cm. (4 to 6.75 inches) and a weight of 55
^^ The umbilical cord is more twisted than in

{cJberg as Hecker's weights and measurements. Spiegelberg,
fd. Soc.,p. 118.

DEVELOPMENT OF THE EMBRYO AND FETUS, 8 1

now disappears. A child bom between the twenty-fourth and
twenty -eighth weeks will usually die.^

Eighth Month. — ^The fetus measures now in length 39 to 41
cm. (15.25 to 16 inches) and weighs 1571 gm. (3)^2 pounds).
The hair on the scalp is more abundant ; the down on the face
is disappearing. One of the testicles, usually the left, has de-
scended into the scrotum. The nails are firmer, but do not yet
project beyond the finger-tips. At the end of the eighth month
ossification begins in the lower epiphysis of the femur. The cord
is inserted a little below (0.6 to 1.2 inches) the middle point,
between the xiphoid appendix and the pubic symphysis. A child
born at this period will, with proper care, survive.

Ninth Month. — The length of the fetus measures 42 to 44 cm.
(16.5 to 17.25 inches) and the weight is 1942 gm. (41^ pounds).
There is a decided increase in subcutaneous fat. The nails are
not yet perfectly developed. Toward the end of this month,
near the thirty-sixth week, the weight will be about 5 ^^ pounds,
and the diameters of the skull about 1 to 1.5 cm. (0.39 to 0.59 in.)
less than in a normal fetus at term.^ At this period also the bones
of the skull are compressible and easily molded to the shape of the
pelvic cavity ; and if at this time, about the thirty-sixth week, the
infant should be born, with ordinary care it will certainly live.

Tenth Month. — During the tenth month (thirty-sixth to for-
tieth week) the fetus is developing from the condition just de-
scribed— that is, characteristic of the thirty-sixth week — into
the infant at term, distinguished by all the features that indicate
the arrival of the fetus at maturity. It is during the last month
of pregnancy that the physiology of the fetus can be studied to
the best advantage. It has now reached a large size and requires
a considerable quantity of oxygen^ for its blood and nourishment

1 There persists, even yet, in the minds of some jjent-ral practitioners, as well as
among the laity, as the writer can testify, the idea that children born in the seventh
month will be more likely to survive than those born at the eighth month. Professor
Parvin ('* Science and Art of Obstetrics ") shows how this superstition has descended,
through more than two tliousand years, from Hip{)ocrates, who explained that the
fetus is placed with its head upi^rmost in the uterine cavity until the seventh month,
when the increasing weight of the head causes it to fall down to the os uteri. As
soon as this occurs, the fetus attempts to make its escape, and if it is strong it suc-
ceeds, but if the attempt fails, it is repeated at the eighth month, and if the infant
now succeeds in escaping from the womb, l)cing exhausted by its previous effort, it is
likely to die.

2 Schroeder, from the measurements of 68 premature infants, gives the average
biparietal diameter of tlu* head as 8.83 cm. (5.5 in.) from the thirty sixth to the
fortieth week ; 8.69 cm. (3.42 in.) from the thirty sec<md to the thirty-sixth week ;
8.16cm. (3.21 in.) from the twenty eighth to the thirty-second week, sliowing that
this diameter, a most im|K)rlant one, is relatively very hirge even early in fetal life.

* That the fetus obtains oxygen from the maternal blood has be«'n proved by
(l) cutting off the bkxKl-supply to the uterus, when the fetus will die of asphyxia
(V'e.«ial, Seyl) ; (2) by the discovery, by means of sj)ectral analysis, of oxyhemoglobin
in the umbilical vein of the cord (Zweifel).
6

:" ' ;:> t:>:>iics, both of which it obtains from the maternal blriod
: ' -^h the nx-vi:uni of the epithelial cells that form the outcr-
r- >: :.:j.1 !.i\cr *.»:" the placenta (the s\Ticytium). From the

• ..: :>.;.: :hc :.:-> undoubtedly swallows considerable quanlitb

; .: r a:r»:::i dunri- the latter months, at least, of pr^nana,^
.. : iv...-::^' that liquor contains a small proportion of
.. .:!V",- s »n:e writers would have it that the fetus deri\e
::- A : . :: .:r..-iinicnt from the amniotic fluid, while the func-
t •• :" : - p'.Accnta i> conrined to the oxygenation of the fetal
— . :;:. ry tb.At h.is not yet found i^eneral acceptana.

• ' > : N- >* :'..v: it ever will. Another fact, however, in its
■ • : - : ^ s-.rvt: n v^f the stomachic glands which is croing

;. ., : . '..ittvT jxriod of intra-uterine life.^ The urine,

- - :. 1 ::: vT^'iisiderable quantity, and which is, as a

r. \. .; .-.^ > \ *ided freely into the amniotic cavit>'.' The

t> -. : ' : :::k\ moves its limbs vigorously, and its

1 .:: -> -^ : . i'.uTuired and twenty to one hundred and

9 • ■

f.\ > \ .'■:'> . 'A

. : t:io tltal blood has certain peculiarities that
.: -. IV-innin^^- at first by a ver>' simple
:- : . .'r heart and four vessels (two arteries and
.: c..rr> the blood to and from the umbilical
Xv-iLv.!.. .: > :'. .issi::r..s tile characteristics that are most DJainlv
iv^ Iv >,.:: .:: r.'o sM^o •:" prci^nancy under consideration. The
b!vvv; : Im: It. is Ivcn o\\i::enated in the terminal villi of the
p!.K\':\M'. :.:::> is retunxvi by veins of increasing^ size to the
lari;e brar.ciies »»:"tlie iiinbilical \ein. which may be seen directly
uiuier tiio amnion «m\ tiio fetal surface of the placenta These
braiK'hes. «. onveri;inL:". unite in the umbilical vein, which is carried
by the cvm\1 to the fetal body, which it enters at the umbilicus.
Thence it runs alvvi^; the anterior surface of the abdominal cavit\*
to the under surface of the liver, where, giving oflT branches to
the IvUnis ijuadratus. lobus Spigelii. and to the left lobe it
di\ i^les into twv> main trunks at the transverse fissure, the larger
o\ which enters the portal vein, while the other empties into the
ascendiiii^ cava aiul is called the ductus venosus. Thus by for
the j:^reatest quantity o( oxyj^^^nated blood that is returned to the
fetus from the placenta must first pass through the liver before
entering the general circulation. The ascending cava conve\^

» ZweifeU ** I'ntcrsuchungon filxT das Meconium," "Arch. f. Clyn.," B^, ^jj jg.^
P 474.

» .\nilorson, " Am. Jour. iM>stetrics.'* Aug., 1 884.

» Krukcnln^rK. «• Maj;ensem»tion des F6lus," ** Centralbl. f. G)m.,'» X*o. 22, 1S84.
♦ RiWxTt, *• VoWr .Mlniminurie des Neugeboren u. des P'otus," Virchow's
Archiv;* IM. xcviii, S. 527.

DEVELOPMENT OF THE EMBRYO AND FETUS.

then to the right auricle a large proportion of arterial blood, but
mixed with it is the venous blood from the lower extremities and
the blood returned from the liver. But this great volume of
blood having arrived at the right auricle, instead of descending
into the right ventricle and
being carried thence to the
lungs, which in their unex-
panded condition could not
contain it, is guided across
the right auricle by the Eus-
tachian valve, and enters the
left auricle by means of an
opening in the interauricular
septum, — the foramen ovale.
From the left auricle the
blood from the ascending cava
enters the left ventricle and is
driven thence into the aorta,
by which it is conveyed pri-
marily to the upper extremity
of the fetus by the ascending
branches of the arch of the
aorta. Here may be seen an
arrangement peculiar to fetal
life, by which the blood is di-
verted from the unused lungs
and conveyed instead to the
aorta. Just beyond the point
at which these branches are
given off there opens into the
aorta a large branch from the
pulmonary artery (the ductus
arteriosus), which conveys the
blood that enters the right
auricle, and then the right
ventricle, from the descending
vena cava, only a small quan-
tity of blood, sufficient for
their nutrition, going to the
lungs. Thus it will be seen
that the aorta conveys a mixed
blood, still further devitalized from the infusion of the venous blood
from the head, neck, and upper extremities, to the trunk and lower
extremities. It is by this arrangement that a greater quantity
of arterial blood is conveyed to the brain, which develops so

Fig. 68. —Diagram of the fetal circu-
lation : a^ijy Aorta; ^, innominate artery;
r, left carotid ; r/, left subclavian; ^, iliacs ;
y, internal iliac arteries ; g^ hypogastric
arteries; h^ pulmonary artery; /, right
ventricle ; /, left ventricle ; k^ ductus ar-
teriosus; /, left auricle; w, left auriculo-
ventricular opening ; «, foramen ovale ; Oy
right auricle ; /, Eustachian valve ; ^, right
auriculoventricular opening; r, vena cava
ascendens ; j, liver ; /, hepatic vein ; «,
branches of the umbilical vein to the liver ;
z/, umbilical vein ; w/, umbilical cord ; x,
bladder ; j, vena cava descendens ; 2,
ductus vcnosus (Flint).

84 PREGNANCY.

rapidly during intra-uterine life. Following the blood-current
down the aorta to the iliac arteries, and then to their internal
branches, two arteries, one from each branch, may be seen
springing upward toward the umbilicus whence they pass out
of the body to form the two arteries of the umbilical cord.
Within the body they are known as the hypogastric arteries.
The two arteries of the cord carry to the placenta what is
usually called venous blood, which, in the terminal placental
villi, discharges into the maternal blood the effete products of
the life-processes in the fetus and receives in return a fresh
supply of oxygen and nutriment, and probably a fair share of
the soluble salts of the blood, as well as any other substance,
medicinal ^ or otherwise, that the maternal blood may contain in
solution or possibly even in suspension.

While the passage of matter from the maternal into the
fetal blood seems to occur so frequently, it would appear to bg
more difficult for substances, aside from the effete products of
tissue-activity, to pass from fetus to mother. There is reason
to believe, however, that the poison of syphilis may take this
course. It has also been demonstrated that certain drugs, as
strychnin, may pass from fetus to mother. ^ The ease with
which medicinal substances will pass from mother to fetus has
given rise to anxiety lest in the administration of powerful drugs
to the mother the fetus might be injuriously affected. ^ It is
possible, of course, to harm the fetus by administering poisonous
substances to the mother, but it is extremely unlikely that the
fetus will be much affected unless the dose to the mother much
exceeds the usual therapeutic limit. But, like the adult, the
fetus may become accustomed to a drug, and be able finally to
endure large quantities of it in the maternal blood. ^

The temperature of the fetus in utero is slightly higher
than that of its mother. Priestley,^ in experiments on rabbits
and cats, found the temperature of the fetus about i° F.
higher than that of its mother, which seems natural enough

^ Chloroform, carbonic oxid gas, salicylate of sodium, benzoate of sodium,
atropin, strychnin, morphin, quinin, corrosive sublimate, iodid of potassium, ether,
urea, the bile-salts, soluble salts of lead, tobacco, sulphindigolate of soda, the germs
of many diseases, have all been known to pass from mother to fetus.

2 Schroedcr, 'Mleburtshiilfe," 8th ed., p. 63.

3 Parvin's *' Obstetrics," 148.

^ I was obliged on one occasion to administer exceeding large doses of BKMpblft
daily for a period of some weeks to a patient who was suffering fiooi .( * ^

cemia in the seventh month of pregnancy. Tne fetus continilff^ **
utero ^ and I could detect no change in the fetal heart-sour*
gave birth to a living infant.

* ** Lumleian Lectures on the Pathology
"Brit. Med. Jour.," 1887, p. 16.

THE MATURE FETUS, 85

if one considers the very great functional activity in the organs
of the rapidly growing fetus, and the fact that the liquor
amnii, although abstracting heat to some extent from the fetal
body, remains itself at a constant temperature equal at least to
that of the maternal body. That the human fetus also pos-
sesses a temperature higher than the maternal body-heat has been
proved by taking the temperature in ano of a fetus coming down
during labor by the breech, and comparing it with the tempera-
ture of the vagina,^ or by taking the temperature of infants
immediately after birth. ^ In these cases the fetal body is found
warmer by o. 5 ° C. than the maternal body.

Of all the organs in the fetal body, the liver seems the most
active. Almost all the arterial blood from the placenta goes
first to the liver. The great quantity of meconium in the
fetal intestines — a substance composed mainly of bile-salts —
attests the active secretory work of this organ, and to it, also,
may be attributed the source of the large quantity of glycogen *
found in fetal tissues, especially the muscles, where this substance
probably has work to perform, the nature of which is not yet
understood.

THE MATURE FETUS.

There is no single sign that enables one to declare a given
fetus to be fully mature ; but the weight, measurements, and stage
of development, taken together, indicate with tolerable accuracy
the length of time that the fetus has remained /// ntcro. By the
two hundred and eightieth day a healthy fetus should weigh about
3317 to 3459 gm. {jYi to 72^ pounds), according to the statis-
tics of Lusk and Parvin ; but in Kurope the weight of the mature
fetus would seem to be somewhat less, for the statistics of Scan-
zoni, Ingerslev, Hecker, Fesser, and BaiMy. including a very large
number of observations, give a weight of less than 3175 gm. (7
pounds). Variations in weight at term between 2728 and 4082 gm.
(6 and 9 pounds) ^ are by no means rare, and the range of possi-
bility in the weight of a mature fetus is a very wide one. Thus

* Wurster, " Berlin, klin. Wochens.," 1869, No. 37, and *• IJeitr. z. Tocother-
mometrie," D. i, ZUrich, 1870.

'See Barensprung, Miiller's " Archiv," 1851 ; Schifer, D. i, Greifswald ;
Andral, **Gaz. H^lxl.," July, 1870 ; Schroeder, V'irchow's ** Archiv," Bd. xxxv, S.
261 ; and the ** Lehrlmch," 8th ed., 1894, p. 65 ; also, Alexeeff, "Archiv f. Gyn.,'*
Bd. X, S. 141.

* March and, **Ueber das Glykogen in einigen fotalen Geweben," Virchow's
" Archiv," Bd. c, S. 42.

* An infant of over nine pounds is not common, while heavier weights are pro-
gressively rare. Out of 1000 infants, Or. Parvin saw but one that weighed II pounds
(Parvin's *• Obstetrics," p. 138). Of 1156 infants born in my service in the Mater-
nity Hospital, the heaviest weighed 12 pounds.

86 PREGNANCY,

Harris ^ tells of one infant that weighed but a pound, and of
another, the child of the Nova Scotia giantess, that weighed
13040.78 gm. (28^ pounds) at term. A decided departure, how-
ever, from the normal average would indicate, on the one hand,
prematurity or a weak development ; on the other, the prolonga-
tion of pregnancy, race peculiarities, the vigor or excessive size
of the parents, especially the mother, or the preoccurrence of
several pregnancies. Sex also influences the size of the infant,
males being, on an average, larger than females. The length of
a mature fetus is 51 to 53 cm. (20 to 21 in.). The width across
the shoulders (binacromial diameter) is about 12 cm. (4.75 in.);
the dorsosternal diameter is 9 to 9.5 cm. (3.5 to 3.75 in.) ; the
biniliac, 9.5 to 10 cm. (3.75 to 4 in.). The length of the foot is
about 8 cm. (3.15 in.).^ The dimensions of the head are im-
portant as a sign of the development of the fetus.

The following dimensions of the fetal head may be consid-
ered characteristic of the normally developed infant directly
after its expulsion from the uterus :

Biteni|wral (H. T.) diameter, 8 cm. (3.15 in.).

Biparietal (li. P.) diameter, 9'^ cm. (3.64 in.).

Occipitofrontal ((). F.) diameter Il^ cm. (4.56 in.).

Occipitomental (O. M.) diameter, 13 cm. (512 in.).

Maximum (M. M.) diameter, 13'^ cm. (5.32 in.).

Suboccipilobregmatic (S. O. H. ) diameter, . 9j^ cm. (3.74 in.).

Trachelobregmalic (T. B.) diameter, . . . 9^^^ to 10 cm. (3.74 to 3.94 in.).
Circumferences: O. K, 34^ cm. (13.58 in.); S. O. B., 30 (11.8); 0. M., 37 (14.5).

These dimensions are subject, however, to considerable
modifications. Any of the causes that tend to increase the size
of the infant as a whole will likewise influence the size of the
head ; but even with a normal body-weight and length the head
may be disproportionately large, without being diseased.

Another valuable sign of maturity in the fetus is the appear-
ance and extent of certain centers of ossification.^ In the
center of the lower epiphysis of the femur may be found at birth
a spot of ossification measuring five millimeters in diameter,
while a similar but smaller spot is just appearing in the upper
epiphysis of the tibia. The center of ossification in the astrag-
alus is to be found without difficulty, for it first appears at the
seventh month of intra-uterine life. The center of ossification
in the cuboid bone is at birth beginning to make its appearance.

1 Note to Playfair's " Midwifery."

2 Negri says (" Amn. di Ostet.," May to June, 1885) that when ^*"
eight centimeters the fetus is well developed and weighs about

3 See Rossi6, *• .\mer. Jour, of Obstetrics," 1886, p. »*J

THE MATURE FETUS, 8/

The ossified spot in the lower epiphysis of the humerus only
appears some months after birth.

The general appearance of a new-born infant is of value as
indicating whether or not the fetus had reached maturity before
its expulsion from the uterus. A healthy infant at term looks
stout and well-nourished. The face is plump and is free from
lanugo ; miliaria are to be seen about the tip of the nose, but
are not nearly so evident as they were in the ninth month of
intra-uterine existence. The eyes are usually opened, the limbs
move vigorously, and the child will seize with its lips the nipple
when presented to it, and will suck with energy. The vernix
caseosa is abundant only on the back of the child and on the
flexor surface of the limbs. The nails project beyond the finger-
tips ; the cartilage of the cars and nose feels firm ; eyebrows and
eyelashes are well developed ; the hairs of the scalp are about
an inch long ; the bones of the head are hard and lie close
together. The breasts in both sexes are large, and usually a thin
fluid can be squeezed out of them. In boys the testicles are
usually to be felt in the scrotum, although the tunica vaginalis
is not yet closed. In girls the labia majora are usually approxi-
mated, although occasionally the nympha: project between them.

The Determination of Sex. — In all countries the number of
male children born exceeds the number of females, the average
proportion being io6 to lOO ; but, as more boys die than girls,
by the time puberty is reached the sexes are about equal in num-
ber. The normal proportion is, however, in modern times much
disturbed by the migratory tendencies affecting chiefly the male
populations of old and long-settled countries. The law that
governs the production of sex has long been a subject of dis-
cussion and speculation. The Hippocratic doctrine that the
right ovary produced boys and the left girls was for centuries
accepted by the majority as the truth, and upon this belief was
founded the precept that women who desired male offspring
should lie during coitus upon the right side, while those who
desired daughters must lie upon the left side. By experiments
upon animals, by the observation of women in whom one ovary
was destroyed by disease, and by a more complete knowledge
of the mechanism of impregnation, the long-accepted teaching
of Hippocrates was disproved, although not until comparatively
recent times. At present it is yet undecided whether the ques-
tion of sex is determined before impregnation occurs. — that is,
whether certain spermatic particles or ovules are predestined to
oroduce males, while others will produce females ; whether the

led upon the ovule at the moment of conception,
'^^■yo is possessed of the elements of both

88 PREGNANCY.

sexes until one or the other acquires a preponderating influence
owing to causes which may be operative during the early part
of pregnancy. The first theory receives its chief support from
the fact that unioval twins are invariably of the same sex, which
looks as though the ovule was predestined in the ovary to the
formation of one or the other sex. The last theory is based
upon the study of plants and lower animals, in which the sex is
only determined at some time after conception by the influence
of nourishment ; overfeeding being found to produce females,
underfeeding to produce males. It is even possible in the case
of certain animals to alter the sex, or at least to produce her-
maphrodites, even after the sexual organs have begun to be dif-
ferentiated. ^ This theory is further supported by the fact
that in the human embryo the elements of both sexes are always
present apparently in equal force during the early part of em-
bryonal life. The belief that the sex of a human embryo is
impressed upon it at the moment of conception rests upon the
fact that in certain conditions of nourishment or sexual vigor in
one or the other parent one sex will preponderate, while under
opposite circumstances the other sex will most frequently be
produced. 2

Disregarding the time at which the sex is determined, the
most diverse conditions have been called upon to explain ap-
parent departures from the normal numerical relation of the
sexes at birth. Illegitimacy, ^ age of parents,'* conception at
certain periods after menstruation,^ deformities in the female
pelvis,^ the nutrition or sexual vigor of the parents,*^ the ten-
dency of each sex to produce the opposite or the reverse,® the

^ In the case of the larvn: of l)eesfrom impregnated eggs, when the female gen-
ital organs have begun to appear, if the nourishment is very insufficient, instead of
becoming female workers these animals will actually develop into true hermaphro-
dites, with the organs of both sexes (Fiirst).

^Thury ('* Zeitsch. f w. Zoologie," 1863, Bd. xiii, S. 541) found in 29 experi-
ments upon cattle that in every case, if connection occurred at the beginning of heat,
females were produced ; if at the end, males.

» Filrst (•* Archiv f. Gyn.," Bd. xxviii, S. I9) says that in illegitimate births the
males fall below the average (based upon 807,332 cases). This coincides with my
experience in the Maternity Hospital in more than looo cases of illegitimate births.

* See Hofacker, *' Leber die Eigensch. welche sich von den Eltem auf die
Nachk. vererben," 1828; Sadler, *• I^iw of Population," London, 1830; Hecker,
"Archiv f. Gyn.," Bd. vii. S. 448; Bidder, "Zeitsch. f. Geburtsh.,*' Bd. ii, S.
358; Ahlfeld, " Archiv f. Gyn.," Bd. ix, S. 448; Wall, " The Causation of Sex,"
London " Lancet,'* 1887, i, pp. 261, 307.

» Thur)-, he. cit. ; Coste, " Comptes Rendus," 1865 ; Schroeder, " Lehibuch,"
8te Aufl., 1884, .S. 33; Hirst. " Kneben Ueberscluiss nach Conception zur Zeit der
postmenstniellen AnSmie." "Archiv f. Gyn," lid. xxviii, S. 18.

•Olshausen, "Klinische BeitrOge," Halle, 1884; Linden, "Hat das enge
Becken einen Einfluss auf die Entstchung des Geschlechts ? " Dis. Inaug., Mar-
burg, 1884; R. Dohm, ** Zeitsch. f. Cieburtsh. u. Gyn.," Bd. xiv, S. 80.

' See FUrst, he, cit.^ and Schroeder, op, ci/.t S. 33. ' See Ftirst, Uc. cit.

THE MATURE FETUS, 89

tendency to produce that sex which is most needed to per-
petuate the species,^ the season of the year, 2 climate and alti-
tude,^ and the degeneration of a race, as during the decadence
of imperial Rome,* — have all been advanced as reasons for ap-
parent excess in the number of male or female births as the case
might have been. All these theories, however, have been found
either false or inadequate upon further investigation. An ex-
planation that appeals to the author's reason is that the indi-
vidual stronger in mental, physical, and sexual attributes will
impress upon the ovule at the moment of impregnation that
individual's sex. A perfectly satisfactory explanation of the de-
termination of sex, however, will be difficult to obtain, while the
production of the sexes at will has hitherto been an impossibility.
Multiple Fetation. — It is the rule that but one fetus at a
time is developed within the uterus of a human female. Once in
about 120 pregnancies,^ however, two fetuses are developed
simultaneously in the same uterus, so that twins are not of un-
common occurrence. Triplets are found once out of 7900,
quadruplets once out of 371,126 births. Quintuplets are ex-
tremely rare. There is one case of sextuplets on record.^
Multiple fetation maybe the result: (i) Of the impregnation
of a single ovum that contains two or more germinal vesicles,
or in which the formative material of the area germinativa
divides ;^ (2) of the impregnation of two or more ova which
were contained either in one Graafian follicle or in separate
follicles, the latter being situated either in one or both ovaries.
There may be a hereditary disposition to multiple fetation.
Boer reported, in 1808, an extraordinary example : * A woman
aged forty had in 1 1 pregnancies during twenty years given birth
to 32 children, to wit : quadruplets twice, triplets six times, twins
thrice. The woman herself was one of quadruplets and her
mother had had 38 children. Her husband was one of twins,
and there was a history of other plural births in his family.

* Diising, " Die Regulirung des Geschlechtsverhaltnisscs bci der Vermehrung
der Menschen, Thiere, u. Pflanzen," Jena, 1884.

' According to Diising i^loc. cit.)^ women impregnated in summer give birth
to fewer boys than those impregnated in winter (conclusions based on more llian
10,500,000 births).

* Ploss found, in Saxony, that up to 2000 feet, the greater the altitude, the larger
was the number of male births (at 2000 feet, 107.8 to loo).

* Darwin's Collected Works.

* According to statistics collected by Veit, based on more than 13,000,000
births, twins occur once in 89 pregnancies ; in New York and Philadelphia the pro-
portion is about I to 120.

* Vassali, *«Gaz. Med. Ital. Lombardia," Milano, 1888, No. 38.
' Ahlfeld, •* Archiv f. Gyn.," Bd. ix, S. 196.

* «« Wien. med. Wochens.," No. 3, 1897.

PA-EG.VANCY.

If the multiple fetation is the result of the impregnation
of a single ovum, there is but one chorion and one decidua
reflexa. although each fetus is inclosed in its own amnion.'
In these cases the sex of the fetuses is the same. The
placenta are usually found intimately united when expelled
at term, presenting extensive arterial and venous anastomoses —
a condition tliat may give rise to the deformity of one of the
twins, known as acardia.
But in the early stages of
development each placenta,
even in unioval twins, is
separate. When the em-
bryos are derived each from
a separate ovum, there
should be separate decidus
reflexa:, chorions, and pla-
centa:. Occasionally, how-
ever, when the ova are im-
planted close together, the
placenta.' may be joined,
there may be but one
decidua reflexa, and it
may be difficult to detect
tiie double layer of chorion
that should separate the
two ova.

Although twins are not
infrequently bom, the con-
dition .should be regarded as
pathological in its influence.
at least, upon the fetus.
From statistics collected by
Schatz,^ it appears that in
twins from different ova one would be born dead in every
twenty-three cases, while from the same ovum the death-rate
would be one in six. One fetus will, perhaps, outstrip its fellow
in growth, and divert the greater part of the nourishment from
the mother to itself, thus growing rapidly and encroaching so
upon the room that should belong to the weaker fetus that the

' Occasionally (wo reiuses tin- round in a. single amniolic cavity, wliich is lo be
explained 1 1) by the ctropliy and absorption of the cnnligiious amniotic walla; (2) by
niplure of ihc amnion in llie latter monlhs from the vigorous movemenla of the
fetus; or (3) by (be development of but a aiagle amnion from the very beginniog
(Myschkin, Vircliow's "Archiv," lid, cviii, .S. 133. 146).
» " Ateliiir f. i;;yn.," Dd. x*\r, S. 438.

Kig. 6<|.-

THE FETAL APPENDAGES, 9 1

latter is killed and finally pressed flat against the uterine wall
(fetus papyraceus). Hydramnios is also very common in twin
pregnancies, and occasionally one fetus is converted into an
acardiac monster. If the fetuses of a twin pregnancy escape
the dangers of intra-uterine life, there are many complications
awaiting them in labor. Should one fetus die during pregnancy,
it is usually retained until term, when the living and dead children
are cast off together, widely different in appearance and develop-
ment ; ^ or else one ovum may be aborted at an early period of
pregnancy, while the other goes on developing until term.^

Even though both children have been retained in utero an
equal length of time, there is usually a marked difference in their
length and weight, especially if they have resided in one ovum.^
In cases of uterus duplex, fetuses of different ages have been
found developing in the two divisions of the uterus. Fordyce
Baker reports a case of delivery of two mature children from a
woman with a double uterus, one male, the other female, at an
interval of two months.'* Upon such cases, and also upon the
fact that of twins in negresses rarely one is light and the other
dark, showing probably different paternity, has been based the
theory of superfetation ; but as there is no clear proof, as yet,
of the occurrence of ovulation during pregnancy, the possibility
of the impregnation of ovules which escaped from their Graafian
follicles at rather wide intervals of time, say weeks or months,
is doubtful.^

CHAPTER IV.

The Development^ the Anomalies^ and the Diseases of the Fetal

Appendag^es : the Membranes, the Placenta,

and the Umbilical Cord«

The study of the development, anomalies, and diseases of
the fetal appendages is necessary to a clear understanding of
fetal pathology. First will be considered the development and
diseases of the fetal appendages springing directly from the

» Schultze, *« Volkm. Samml. klin. Vortrage," No. 34.

* Sirois, **L'Union m^dicale du Canada," July, 1887; and Warren, "Am.
Jour. Obstetrics," 1887.

* Schatz, loc. cU.

* See Lnsk, op. cit., p. 233, ed. 1886.

* For some interesting observations which would seem to indicate the possibility,
at least, of ovulation during pregnancy, sec " Ovulation During Pregnancy," Chris-
topher, "Am. Jour. Obstetrics," 1886, p. 457.

92 PREGNANCY.

embryo — namely, the amnion, the chorion, the allantois, and
the placenta ; lastly, the decidux, the maternal envelope of the

fetus.

THE AHNIOT4.

After segmentation has occurred, and after the interior of
the ovum has become reduced to a granular mass, around which
is a membrane composed of a single layer of cells, at a certain
point — the embryonal area — in this membrane there appears a
thickening, by a heaping up of the cells. Finally this mass of
cells resolves itself into two layers (ecto- and entoderm), and
between the.se two appears another layer of cells (mesoderm).

The outer layer, the ectoderm, sends a prolongation around
the whole interior surface of the ovum, and this layer receives a

', Kinbryo ; ff, cepliali

I, amnion

Fid- 71 f, Embryo

, amniotic umliilicus ; l.h, smnio
urimial cavity ; //, pp, pleuroperilo.
al cavity; tk, chorion; tm/, vilel-
le memlirane ; vs, umbilical Tcsicle.

reinforcement from the middle layer of cells, or the mesoderm.
As now the embrj'O begins to assume a definite shape, and the
lateral walls begin to fold in toward one another, and the caudal
extremity approaches a little to the cephalic end of the embryo,
giving it the arched back characteristic of the young embryo,
the outer layer of cells, forming a membrane continuous with
the outer covering of the embryo, instead of being simply car-
ried forward to meet in the median line in front, sends reduplica-
tions backward over the dorsal aspect of the embryo, which
shortly meet and join one another. There are consequently two
cavities formed, — one within the membrane doubled back upon
itself; the other between the inner (the true amnion) of the two
layers of membrane and the outer covering of the embryo. The

THE AMNION. 93

latter is the true amniotic cavity, which is gradually more and
more distended by the accumulation of fluid until the membrane
which contains it is pushed out on all sides, uniting in front
around the umbilical cord, and coming in contact throughout
the whole extent of the ovum with the outer membrane (true
chorion), to which it becomes loosely united by a gelatinous sub-
stance,— the tunica media of Bischoff.

The Fully-developed Amnion. — The amnion forms the
innermost of the membranes that surround the fetus at term.
It is continuous with the fetal epidermis at the umbilicus, and
forms a complete sheath for the umbilical cord, and also covers
the fetal surface of the placenta. In its structure it consists of a
single layer of flat endothelial cells turned toward the cavity of
the amnion, and externally of a layer of young connective tissue,
in which may be seen long spin-
dle- or star-shaped cells with
long nuclei imbedded in a fibrous
substance (Schrocdcr). The reg-
ular disposition of the inner
layer of endothelial cells, how-
ever, is disturbed at certain
points of the amnion lying over
the placenta, where there may be
seen numbers of cells heaped
together, forming a little villus-
like projection. There are, nor-
mally, no blood-vessels in the
amnion,— at least, in its later . ^'^- ^f-^^'PP^^*'^" ''^/^%-'?'

' ' . nion : «, Umbilical vesicle ; /, pedicle

Stages of development; their of the allantois ;«, amniotic cavity.

possible occurrence, however, in
hydramnios will be referred to later.

The Liquor Amnii. — It is the physiological function of the
amniotic membrane to furnish a fluid medium (the liquor amnii),
which distends the uterine walls and allows the fetus some free-
dom of movement, and, by its density, approaching the specific
gravity of the fetus, robs these movements of much muscular
effort. It acts as an additional protection to the fetus from ex-
ternal violence, pressure, and changes of temperature ; it receives
the urine secreted in the latter part of fetal life ; and, perhaps,
has some little part in the nourishment of the fetus, or at least
in supplying the fetal tissues with that excess of water which
they have been shown to possess during intra-uterine life. ^
That the fetus actually swallows considerable quantities of

^ Preyer, " Physiologic des Embryos."

94 PREGNANCY.

liquor amnii admits of no doubt, for not only have lanugo and
epidermis-scales been found in the meconium,^ but also particles
of colored matter which had entered the amniotic fluid from the
maternal structures (Zuntz). It is not likely, however, that the
liquor amnii plays an important part in the nutrition of the
fetus, as claimed by von Ott and others ; for if it did, the birth of
well-nourished children with a breach of continuity in the upper
part of the alimentary tract from the mouth to the small intes-
tine would be inexplicable.

The Composition of tlie Liquor Amnii. — The amniotic fluid is
usually almost clear ; occasionally, however, opaque, whitish,
greenish, or a dark brown from the presence of meconium, or of
a reddish color when the fetus is macerated. The specific gravity
varies from 1002 to 1028 (Schroeder), being usually, however,
about 1007 to loi I. Its reaction is slightly alkaline. It contains
salts, urea, carbonate of ammonia, kreatinin, albumin, lanugo,
sebaceous matter, epidermis, scales from the fetal skin, and epi-
thelium from the bladder and kidneys. The quantity of the liquor
amnii differs at different periods of pregnancy : in the early stages
it develops with great rapidity, and at the middle of pregnancy has
reached its maximum of about i to 1.5 kilograms (2.2 to 3.3
pounds) (Landois). From this time it diminishes in amount, until
at the end of pregnancy its average quantity is 680 gm. (1.5
pounds). 2

The Orig:in of the Liquor Amnii. — The origin of the liquor amnii
has been attributed to a maternal source, to the fetus, or to both
mother and fetus. The last view is doubtless correct. The
maternal origin ^ of the amniotic fluid has been demonstrated by
Zuntz, who injected sodium sulphindigolate into the veins of
pregnant rabbits, and found a blue coloration of the amniotic
fluid, although there was no coloring matter in the kidneys of
the fetus. As further evidence might be cited the fact that there
are cases in which the embryo is destroyed very early, but in
which an amount of amniotic fluid may be found corresponding
not to the age of the embryo, but to that of the ovum. And,
moreover, it is not unusual to find hydramnios associated with
some other serous effusion in the mother.'*

1 Zweifel, ** Untersuchiingen iiberdas Meconium," "Archivf. Gyn.," Bd. vii,474.

2 Fchling, " Archiv f. (iyn.," \V\. xiv, S. 221.

^•Ahlfeld (*' Uebcr die (ienesc d«^^ IVuchtwasscrs," "Archiv f. Gyn.," Bd. xiii,
pp 160-241) j^ives an ingenious exjilanation ol llic manner in which the maternal
structures take part in tlie formation of the h(|uor amnii : As the uterus develops by
an eccentric hvpertiophy, the pie>sure within the uterine cavity becomes less than
that of the alxlominal cavity, and conseciueiitly there is a disposition for the serum of
the maternal i>lo()(l to exude into the amniotic cavity. As PhiUips (** Edin. Med.
Jour.," March, 1SS7, p. Sii) ninarks. however, the case of hydramnios in extra-uterine
pregnancy ("Archiv f. Gyn.," YA. x\ii, |>. 57). reported by Teuffel, wouUl seem to
invalidate tliis theory.

■* I'fluger's " Archiv," I5d. xvi, S. 54S ; and Wiener, " Archivf. Ciyn.," Bd. xvii,

S. 24.

THE AMNION. 95

The fetus also contributes to the formation of liquor amnii,
as is demonstrated by the fact that the excretion of urine
during the latter part of fetal life reaches a considerable amount.
Thus, more than three pints of urine have been found retained
in the fetal bladder. ^

Gusserow ^ has injected benzoic acid into the mother, and
recovered it as hippuric acid in the liquor amnii, — a proof that it
had passed through the kidneys of the fetus ; and Wiener has
found sodium sulphindigolate in the fetal kidneys and bladder
after it had been injected into the maternal tissues. The constant
presence of urea ^ in the amniotic fluid, at least after the sixth
week, is an additional proof, if one were needed, of the renal
activity of the fetus. It is probable also that the vasa propria,
discovered by Jungbluth,* in the early life of the embryo lying
close under the amnion, have something to do with the produc-
tion of the amniotic fluid in the earlier periods of pregnancy.
Prochownik ^ claimed that the skin of the fetus secretes
amniotic fluid during the early months of gestation ; and there
has since appeared corroborative evidence of his view. There
have been cases of hydramnios associated with morbid con-
ditions of the skin, notably one instance observed by Budin,^ in
which the skin of the fetus was the seat of extensive nevi. Thus
it appears that the amniotic fluid is derived from a fetal as well
as a maternal source, but the relative importance of the fetal
and maternal supply of liquor amnii at different periods of preg-
nancy is still undetermined.

Abnormalities of the Amnion. — There is a striking simi-
larity between the pathology of the amnion and that of other
serous membranes. There is the same liability to changes of
secretion, to inflammation with a plastic exudate, and to the for-
mation of bands of adhesion. The function of the amnion, how-
ever, and its close relation to the embryo and fetus, give rise, in
case of disease, to symptoms and results peculiar to itself

Abnormalities of Secretion : Oligohydramnios. — The quantity
of liquor amnii varies, at term, between one and two pints.
Occasionally, however, the quantity of fluid is very much below
the normal — so much so in some cases as to seriously interfere
with the growth of the fetus and to determine its premature

^ I>efour, '* Archives de Tocol.," June 30, 1S87.
2«* Archiv f. Gyn.," Bd. xiii, S. 56.

• Prochownik, ** Archiv f. Gyn.," Bd. xi, S. 304-561.

* ** Beitr. zur Lehre v. Kruchtwasser," Inaug. Dissert., Bonn, 1869; Virchow's
"Archiv," Bd. xlviii, S. 523 ; '* Archiv f. Gyn.," Bd. iv, S. 554.

* Loc. cii.

• Tamier et Budin, loc. cit. , p. 279.

rilR AMNION, 97

of liquor amnii is derived probably from a maternal source.
Fehling ^ asserts that ** the thinner the maternal blood, the
greater is the quantity of liquor amnii." It would be well,
therefore, to examine the blood of a patient who was affected
with hydramnios, in order to detect a possible exaggeration of
the usual hydremia of pregnancy. A lymphagogue has been
found in the liquor amnii of hydramnios, which is not present in
the normal liquid. It has been claimed, therefore, that this sub-
stance stimulates a serous exudate from the maternal blood. ^

II. The Hydramnios May Originate Entirely from Fetal
Structures, — ^This supposition will explain by far the larger
number of cases that admit of an explanation at all, for hydram-
nios often occurs (forty -four per cent, of all cases (Bar) ) without
a demonstrable cause in either mother or fetus. The production
of hydramnios, traced to the fetus, may be due : (a) To abnormal
pressure in the blood-vessels of the cord, or of those directly
under the amnion, where it covers the placenta (persistence of the
vasa propria of Jungbluth); {b) to an excessive urinary secretion ;
(r) to an abnormally profuse excretion from the fetal skin.

{a) The vasa propria of Jungbluth, normally present in the
early stage of embryonal development, have been found at term
in cases of hydramnios,^ and the production of an excessive
quantity of liquor amnii has been attributed to their persistence.
It is more probable, however, that the existence of these vessels
is purely secondar>% and that, although the serum of the fetal
blood does exude from them into the amniotic cavity, their
presence is due to an increased blood -pressure in the umbilical
vein.* Increased internal pressure w-ithin the umbilical vein
will give rise to a transudation through the amnion as has been
abundantly proved by Salinger,^ who found that the amount of
fluid which would transude depended upon the strength of the
pressure and the size of the cord. Any condition of the fetus,
therefore, which will raise the blood -pressure in the umbilical
vein, thus increasing the blood-pressure in the placenta, may
give rise to hydramnios. This happens, for example, in cirrhotic
livers common in s>TDhilitic children. There are many other
conditions having the same effect — a cord abnormally twisted,

> ** Archiv f. Gyn.," B(l. xxviil, S. 454.

» E. Opitz, "Centralbl. f. Cyn.,** No. 21, 1898.

^ l^vison, ** Archiv f. (lyn." Bd. ix, S. 517; Lebedjew, ** Trait6 prat, des
Ace.,*' C'harpentier, 1883, p]). S86, 890.

* Winckler denies the existence of a cajnllary system of blood-vessols under the
amnion, and attributes hydramnios to llie presence of a capillary lymphatic system in
the cell-layer of the chorion.

•**Uebcr Hydramn. in Zusamm. mit der Entstehung des Fruchtw.,'* D. i.
Zurich, 1875.

98 PREGNANCY.

velamentous insertion of the cord (exposing the vein to external
pressure), stenosis of the umbilical vein, obstruction of the ductus
Botalli,^ tumors of the placenta, tumors of the fetus (interfering
with its circulation), valvular defects of the heart, ^ etc.

(b) Excessive excretion of urine is a cause of hydramnios.
The action of the fetal kidneys in the production of hydramnios
can best be demonstrated in cases of unioval twins, ^ in one of
which it is common to find a dropsical amnion, while the other
one presents usually the opposite condition, oligohydramnios.
The history of these cases is that one fetus outstrips the other
in growth, and thus, acquiring a preponderating influence in the
placenta which is common to both, its heart takes on a hyper-
trophy to enable it to carry on the greater part of the placental
circulation. The hypertrophied heart produces in its turn hyper-
trophy of the kidneys and determines their increased secretion.
The increased blood -pressure also determines an increased activ-
ity of the excretion from the skin, and thus in a twofold manner
helps to increase the quantity of liquor amnii.

(r) The fetal skin is a source of hydramnios. It can readily
be understood how an increased blood-supply from a hyper-
trophied heart can stimulate the fetal skin to overaction. There
are, however, more direct proofs of the part that the skin may
play in the production of hydramnios. Budin * has described
a case of hydramnios associated with extensive nevi, and another
in which the skin was thickened and thrown into folds. Stein-
wirker ^ has recorded a case of hydramnios with "elephantiasis
congenita cystica."

Finally, it is not improbable that the amnion itself may take
an active part in the overproduction of liquor amnii ; that, in other
words, the amnion may be affected by acute inflammation (amnio-
titis), followed by an increased serous exudation. This supposi-
tion would explain those cases in which a blow or kick ^ on the
abdomen of a pregnant woman is followed by the development
of hydramnios and the formation of adhesions between the
fetus and the amnion. To amniotitis has been attributed the
development of acute hydramnios. Werth's ' theory also de-
serves some consideration before leaving the study of the fetal
origin of hydramnios. This author believes that a hypertro-

* Niebcrding, *• Zur (ienese des Hvdraninio<.'' •• Archiv f. Gvn. ,'* Bd. xx,
S. 275.

^Cordell, •' Tr. Med. and riiinin: F.u\ Manl.ind/' 1888, p. 2lS.

* Schalz, "Archiv f. c'.yn, " \\A. xix, S. ^;2g; Werth, ibiJ., xx, 353; Sallinger*
loc. cit. ^ I : . ...'. -'> Ziv. .;/.

* ** Tr. (>l>stet. Sac. of n.jhimoio." meeting Feb. o. 1887.
^ Werth. hw cit.

THE AMNION, 99

phied placenta can absorb more fluid from the maternal blood
than is required for the fetal economy ; that the struggle to get
rid of this excess of fluid brings about the hypertrophy of the
heart and kidneys to which reference has already been made as
occurring especially in one of unioval twins.

III. Both Fetus and Motlur May Contribute to the Production
of an Excess of Liquor Amnii. — ^This proposition has already
been demonstrated in showing the possible derivation of the
liquor amnii from both mother and fetus. The cause of the
hydramnios, however, will most frequently be found in the fetus,
while the combined action of both mother and fetus in a single
case will be rare, but may occur, as in certain cases of syphilis, in
which have been found combined dropsy of the mother and fetus
associated with hydramnios.^

B. Hydramnios may be due to a deficient absorption of
liquor amnii. Tarnier believes that the production of liquor
amnii being normal, but its absorption deficient, hydramnios will
result. Thus he would explain the cases of hydramnios asso-
ciated with nephritis and serous effusions in the mother.

It has been proved that the fetus swallows the liquor amnii
in considerable quantities, and it is possible that the skin absorbs
some of it. Whether the cessation of these two functions would
result in hydramnios is uncertain.

Symptoms and Diagnosis. — ^The symptoms of hydramnios
are very like those of other abdominal cystic tumors. There is,
however, the history of pregnancy ; the tumor can usually be
defined as the uterus, very much larger than usual for the date
that pregnancy may have reached ; and, except in extreme
cases, it is possible to detect the fetal heart-sounds, or to
practice ballottement. As the uterus becomes more and more
distended it gives rise, by its increased size, to pressure symp-
toms in the abdomen and thorax, although it is astonishing to
what size the uterus may attain, while the patient remains toler-
ably comfortable. This is not the case, however, when the
liquid is rapidly effused, as in cases of acute hydramnios. The
woman suffers intense pain from the sudden distention of the
uterus. Her breathing becomes labored, and complete or-
thopnea is developed ; her face is cyanosed and bears an
anxious expression ; constant and distressing vomiting appears,
and there is fever. ^ The detection of hydramnios is not always
easy, and may be practically impossible. It may be confused
with pregnancy associated with ascites, or with a cystic tumor

* Meissnerand Ilufeland, quoted by Wilson, "Am. Jour. Ol)stetrics," 1887, p. 13.
' Sec Charpentier, " Trait6 Pratique des Accouchements."

lOO Ph:EG\'ANCY.

of the ovary or broad ligament, or with an ordinary twin preg-
nancy ; or the fact that the woman is pregnant may be entirely
overlooked, — a not uncommon mistiike that has frequently led
to the tapping of the pregnant womb ;' this procedure, however,
appears to be harmless. Finally, it might be possible to mis-
take the enlarged bladder associated with a retroflexed gravid
Uterus for a case of hydramnios (Tamier). When the dropsy
of the amnion has not
reached an excessive de-
gree, the distinction be-
tween it and ascites with
pregnancy may be made
Ijy mapping out the uter-
ine wall and detecting
resonance along the
flanks in the dorsa! de-
cubitus ; and an ovarian
cyst in pregnancy may
be excluded by the ab-
sence of two tumors of
different consistency and
shape. A twin preg-
nancy without hydram-
nios will present, on ex-
ternal palpation, an en-
larged uterus, oflering
firm but irregular re-
sistance from its solid
contents. In extreme
distention of the uterus,
which in some cases
seems only limited by
the utmost capacity of
the abdomen, a definite
diagnosis becomes im-

ODC pinl (autliur'

possible ; in such cases it may be justifiable to resort to an
exploratory abdominal section.^

Trcalnicnt. — If the fluid should accumulate in such quantity
or so rapidly as to produce alarming symptoms in the woman,
its evacuation is indicated. This is best accomplished by the
natural passage ; that is, by rupturing the membranes through

t, SchaiE, Tillaud, ChUro,

t diitenlion of Lhe abdonteii (nun

THE AMNION, lOI

the cervix and allowing the liquor amnii to escape. By this
method, unfortunately, labor is induced, and if the child has not
become viable, its destruction is a necessary consequence. And,
moreover, the sudden gush of liquor amnii from the uterus may
induce syncope by the rapid removal of the intra-abdominal pres-
sure, or may result in excessive tympany from the sudden relief
of pressure on the intestines. It has, therefore, been proposed
(Guillemet, Schatz) that the uterus be tapped through the ab-
dominal walls, and a moderate quantity of liquor amnii be re-
moved from time to time, thus preserving the life of the fetus.
As, however, the fetus in cases of hydramnios is often deformed
or diseased, and usually dies shortly after birth, its life deserves
little consideration in comparison with the additional risk that is
undoubtedly entailed upon the mother by puncturing the ab-
dominal and uterine walls. It is especially in acute hydramnios
that puncture of the membranes will be called for, irrespective of
the age or condition of the fetus.

Special instruments have been devised for the perforation of
the membranes, and it has been suggested that the puncture be
made at a point far within the uterine cavity, and thus removed
from the external os, so that the liquor amnii may trickle slowly
down between the membranes and the uterine walls, and the
disadvantages of a sudden escape of the fluid be thus avoided.
No better or more convenient appliance can be found than the
tip of the forefinger. The hand that is introduced into the vagina
to dilate the cervix and to rupture the membranes may be
clinched so as to form a quite efficient plug, by means of which
the operator may regulate at will the escape of the liquor amnii.

Abnormalities of the Liquor Amnii in Color, Consistency ,
and Chemical Constitution — The liquor amnii, which is nor-
mally somewhat opaque and whitish m color in the last months
of pregnancy, may be green or brown from the presence of
meconium, or it may be tinged with red if the fetus is macerated.
The consistency of the fluid in extreme cases of oligohydramnios
is that of thick syrup or of mucus. It may contain sugar if the
mother has diabetes mellitus. ^

Putrefaction of the Liquor Amnii — Decomposition of the
liquor amnii is most likely to be associated with death and putre-
faction of the fetus, but an intensely putrid odor of the fluid,
with physometra, has been noted, and yet the child was born
alive.

Adhesive Inflammation and the Formation of Amniotic
Bands. — Early in embryonal life, in case the amnion is not

* Ludwig, "Centralbl. f. Gyn.," No. II, 1895.

PREGA'^NCy.

lifted away from the newly-fonning skin of the embryo, owing to
an insufficient secretion of amniotic fluid or as a consequence
of inflammation, adhesions may form between the skin and
amnion, and as the amniotic cavity becomes distended, the
adhesive material is stretched, so that it finally forms bands of
greater or less length or thickness, either connecting the fetus
with the amnion or with one or other or both ends detached,
floating more or less free in the liquor amnii. The composition
of these bands closely resembles that of the plastic material
thrown out in inflammations of the serous membranes generally.
They arc not provided with blood-vessels. The exudation
of this plastic material from the
amnion has, as a result, the for-
mation occasionally of extensive
adhesions between the fetus and
the amnion, resulting often in
grave deformities, as eventration
or anencephalus, by preventing
the proper arching over of the
walls of the body -cavities. The
formation of adhesive bands is
sometimes followed by intra-
uterine amputations. A de-
veloping limb may be caught
between two of these bands,
and as it grows may be so con-
stricted that the distal portion
of the limb is entirely cut off
from its blood-suppiy. Adhe-
sions may also be formed be-
tween various portions of the
body and the amniotic covering
of the placenta, or the umbilical
cord may be artificially shortened by the adhesions of coils one
to another and to the fetal skin. ^

In the latter part of pregnancy the amnion may burst, the
integrity of the ovum being preserved by the chorion.^ The
fetus then, by its active movements, can roll the amnion up into
cords, which may become so entangled with the umbilical cord
as to con.strict it sul^ciently to obliterate its blood-vessels.

Cysts of the Amnion. — Cases of cystic formations in the
substance of the amnion have been reported by Ahlfeld, Winc-

' Leopold, ■■ Ein F5lui mi
Gyn.." Bd. xi, 383.

* Schroeilet, " LelitUlch,"

Vetklebungen der Nabebchuur." i

THE aiOtilON.

kcl. and Budin, • They are small and have no clinical signifi-
cance. After the death of the fetus the amnion undergoes
certain changes, resulting in a loss of its glistening surface and
in a considerable thickening. The histology of this change is

not known.

THE CHORION.

When the ovule first drops into the uterine cavity and be-
comes imbedded in folds of the thickened uterine mucous mem-
brane, the protoplasmic cell-wall of the ovum sends out numerous
prolongations, which serve to fix the egg in its position, and

perhaps to draw nourishment for the whole ovum from the blood-
vessels of the uterine mucous membrane. This cell-wall, with
its villus-like projections, constitutes the false chorion, which
soon disappears and is replaced by the single layer of ceils
springing from the outer layer of the blastodermic membrane and
surroundin[^ the whole ovum. This membrane, in its turn, sends
out branch-like processes (the villi of the chorion), which, at first
non-vascular but hollow, soon receive into the interior of each
branch of the villi loops of the blood-vessels that have been carried
from the fetus to the periphery of the egg by the allantois.
' Tarnicr et Budin. lot. Hi., p. 274.

I04

FREGNAi\-CY.

These vascular villi absorb nutriment from the whole ex-
tent of the decidua reflcxa until the third month, wlien they
atrophy and finally disappear, except at that portion of the
periphery of the ovum which is in direct contact with the decidua
vera (decidua serotina), where the chorion villi develop still further
to form the placenta.

The Fully-developed Chorion. — Restricting the term chorion
to that portion of the original membrane which undergoes
atrophy at the third month of pregnancy, it is found to consist
of a thin, transparent membrane made up of connective -tissue
elements which are continuous with the substance of the umbili-
cal cord and very delicate, atrophied villi connecting it with the
decidua reflexa. This portion of the chorion is called chorion
Ixve to distinguish it from the
chorion frondosum that forms the
placenta. The fibrous mem-
brane, constituting what is usu-
ally called chorion at term, is
derived from the endochorion,
so called to distinguish it from
the outer epithelial layer (the
cxochorion), which is to be found
persisting in the epithelial cover-
ing of the placental villi.

Diseases of the Chorion. —
An abnormal condition of the
chorion is the persistence of the
chorionic villi around the whole
periphery of the ovum, thus com-
pletely enveloping the fetus by
the placenta (placenta membran-
acea). ' The degenerations, aside from the normal process of
atrophy, that may affect the chorion villi are of two kinds, —
cystic and fibromyxomatous.

Cystic DeKeneratlon of the Chorion Villi. — This disease is char-
acterized by the hypertrophy of the chorion villi, by their conver-
sion into cysts varying in size from that of a millet-seed to the
size of a grape or even of a hen's egg, connected with one an-
other and with the ba.sc of the chorion by [Kdicles of varying
the rapid growth of tlie
consequent expansion

Fig. 76.-IIi,man em
third week, showing villi <
enlire chorion (Haeckel),

ivering the

) the third to i

[^ of blood from
txpul-

THE CHORION. 1 05

sion of the ovum, which is covered over a greater or loss part of
its surface with numbers of small, transparent cysts. Within the
cavity of the ovum may or may not be found an embryo.

This affection of tht; chorion, from the peculiar and striking
appearance that it gives to the ovum, has attracted much atten-
tion, and. from the mystery that formerly surrounded its origin
and the diflerence of opinion that existed as to its etiology
and minute anatomy, cystic degeneration of the chorion villi,
otherwise known as hydatidiform mole, or dropsy of the chorion
villi, has been the subject of much discussion. First definitely
described bySchenk,' the most extraordinary theories have been
advanced to account for its occurrence. Regnier de Graaf (1678)
believed that each vesicle or little cyst was an unfecundated
ovule. But much earlier than this the belief had prevailed that
each vesicle was a living embryo.* The opinion of Ruysch
(1691) and Albinus (1754), that the
existence of innumerable little cysts
in the uterus and their final expulsion
were dependent upon some disease
or alteration of the ovule, became
at last generally adopted. A more
definite explanation, however, was not
attempted until, in the early part of
this century, it was claimed by Percy, ^
Cloquet.* and Mme. Boivin * that the
vesicular disease depended upon the
presence of echinococci. Velpeau ^
was the first to indicate that the
cj'sts were nothing but the dis-
tended chorion villi. — a fact that was
soon acknowledged to be indisput-
able. Since Veipeau's announcement.
c>"stic degeneration of the villi has been attributed to hypertrophy
and edema (Meckel, Gierse) ; to disease of the blood-vessels
(Bartolin. Miller. Cruveilhier) ; to disease of the lymphatics (Bid-
los, Sommerring) ; to degeneration of the mucous substance within
the villi, continuous with the substance of the cord (Virchow) ;
to a degeneration of the epithelial cells derived from the dccidua.

Fig- 77— Cystic

Smyxunia) of the chorji
oliclifurm mole.

' See '■ Tamicr ei Budin." p. 199.

'See ibe inleicsling i^milation by Priealley (he. cit,. p. 36) fmni Ambroise

P!«*. thai '■ Ihe Cowitess Matgaret bmuglil forth U one bjrlli 365 infanta, wliereof

" ■oeic «iid In be males. H5 many females, and the odd one a hermaphnKliie "

A. D.). " ■■ jour, de MM.," 1. xiii, p. 171. 1811.

No. I, "De laFannedes Mfid.." FrieMley.

' Nouvelles Kecherches sur le Male vfsiculaire," broch., Paris, 1SZ7.
De VKn des Accuuchcmtnis."

io6

PREGNANCY.

which replace the epithelial covering (exochorion) of the chorion
(Ercolani) ; and, finally, to a pathological hyperplasia of the
syncytium. Virchow's ' explanation is that the change resulting
in the cystic degeneration of the chorion villi takes place altogether
in the endochorion, which forms the inner of the two layers that
compose the chorion and is continuous with the Wharton jelly
of the umbilical cord; this change consists of the overproduction
of true mucous tissue within the villi, into which the mucous tis-
sue extends at first alone, but afterward accompanied by blood-
vessels. The process usually begins at a time when the villi
are almost equally developed over the whole ovum. — that is,

Fig. 78.— Cystic degei

of the chorion (from a pbolograpb) .

before the third month, — and, therefore, when the vesicular,
chorion is expelled the disease is usually found equally distributed
over the whole surface, showing no evidence of special develop-
ment at any one point that might indicate where the placenta
should have been situated. The general involvement of the whole
chorion is the rule, but exceptionally the placenta alone is
affected, the disease having doubtless, in such cases, begun
after the atrophy of the villi had taken place over the extra-
placcntal portion of the chorion. Still more rarely will the

■■ Die Knnkharien CeschirUhte," Bd. i, S. 405.

THE CHORION.

107

disease be found in isolated spots upon the chorion tfeve.^
There are recorded cases in which one chorion of a twin concep-
tion was vesicular while the other remained normal. According
to the foregoing explanation, the disease is a true myxoma of
the chorion, and the epithelial cells (exochorion) covering the
villi do not necessarily take part in the morbid process, Priest-
ley's ' investigations, undertaken as long ago as 1858, gave
results in accord with Virchow's theory.

Pathologicf^ Anatomy, — The appearance of a vesicular mole
is striking and peculiar. The mass may be as large as a man's
head, covered more or less completely with decldua, which, upon
incision, or in spots where the decidual covering is absent, reveals
innumerable small cysts, some as large as grapes, or even as
hens' eggs, connected one with the other or with the base of

fig. 79. — A, Enlremity of a villus in early stage of cyslic ilegenc ration ; a. Shows
the first stage of enlai^emciil in the cells of the villus trunk ; *, a somewhat mote
advanced stage, showing hyaline cells escaping; from Ilie tu]i[ured capsule of a young
cyst (Priestley). B. Terminal villus of cystic chorion ; a. Stellate connective (issue ;
b, c, inner and outer layers of wall ; d, early stage of b (Braxton Ilicks).

the chorion by pedicles of varying thickness. The liquid
in the cysts is usually clear and translucent. A microscopic
examination of a section through a villus in the early stages of
cystic degeneration shows the distended cells of which Priest-
ley speaks, or el.se there may be seen the outer cellular and
inner fibrous wall of a villus, while within the interior are .stellate
connective -tissue cells, in the interstices between which may be
found mucous tissue.

The fluid contaipcd in the cysts gives evidence, on chemical
examination, of the presence of mucin and albumin in consider-
able quantities.

' Wint^radow, Virchow's "Archiv,"' 1870, Bd. li, S. 146.

io8

PREGNANCY.

Within the center of the vesicular mass is usually to be found
a shriveled or distorted fetus surrounded by its amnion, which
occasionally contains an abnormal quantity of fluid (hydramnios).
Occasionally, however, no trace of the embryo is to be discov-
ered, or at most there may be seen only the remnants of an
umbilical cord. Mure rarely the fetus, although dead, is appar-
ently well developed for the date of pregnancy/ and if the de-
generation of the chorion has not been too extensive, a living,
healthy infant may be bom along with a vesicular chorion.* It
has been already noted thai between amnion and chorion may
be found a thin layer of Jelly-like substance continuous with the
Wharton's jelly of the umbilical cord. There is a case on rec-
ord ^ in which this substance formed a layer four to five milli-
meters thick, originating from a mucous degeneration of the

V^ ^

Fig, So.— Hydatid i form mole, show- Fie- Si.— Miumpln-iivt;!],!. of mv:.-

tng myxomaioiu dcgi-ueralion of ibc villi oma oi ihe ciiotioii \ W illiam?).
of tlie clinrioii, wilii pmlifeialimi of ilie
»yncyliuiii (Williiiinii).

connective-tissue layer of the chorion, without involvement of
the villi of either the chorion la:ve or frondosum, thus consti-
tuting a peculiar and, up to the present time, unique variety of
myxoma of the chorion.

TliL- relation of the cystic chorion to the two decidual is
often peculiar and complicated. Occasion,illy the membranes
retain their normal relative position of external decidujc, mcdi.in

' IVi.-.(l.

k 442; am] Sym,

THE CHORION. 109

chorion, and internal amnion ; but frequently the enlarged villi
of the chorion perforate either one or both decidu.x over surfaces
of varying extent. Thus, specimens have been described ' in
which the cystic mass was inclosed between the decidua vera
and the reflexa, or in which the villi have perforated not only
both decidu.'u. but also the muscular wall of the uterus, and
even its peritoneal covering.^ The relation of myxoma of the
chorion to syncytial cancers is quite intimate. In a large pro-
portion of the latter growths there is associated a cystic disease
of the chorion villi. The cases formerly reported of malignant
degeneration of the chorion were unquestionably of this charac-
ter. There may be a metastasis of whole chorion villi, without
a malignant degeneration of the epithelial cells. ^

Clinical History and Diagnosis. — There are three prominent
symptoms associated with the cystic degeneration of the chorion :
(i) Rapid increase in the size of the uterus ; (2) discharge of
blood or bloody serum, and {3) the escape of vesicles. The
last symptom is of rare occurrence, and the first two do not
always manifest themselves in a typical manner, so that the
clinical phenomena in a case of vesicular mole do not always

permit of a definite diagnosis. Should there be an escape of
blood at intervals during the early part of pregnancy, if the uterus
rapidly enlarges toward the third month, and if careful palpa-
tion elicits no sign of tiie presence of a fetus within the uterine
cavity, the existence of a cystic chorion may be suspected. If.
as rarely happens, characteristic cysts are expelled, there can be
no doubt as to the nature of the case. The sudden distention
of the uterus usually causes excessive nausea and vomiting.
Occasionally, after the development of the chorion villi, the dis-
ease is arrested and the ovum is retained for many months, so
that in such cases there may be all the symptoms of pregnancy,
with a previous history of bleeding, but the womb at the time
of examination is much smaller than it should be at the date
which the pregnancy has apparently reached. Vesicular mole
is most apt to occur in women who have already borne ciiildren

' Prieslle]', /or. nV., p. 40.
' Coiy, quoted by Prieslley
quoted bf Schroeder. op
■ ■ ■ ■'r, of the Gyn, !

Volkmann, WnWfyer. Jarotzky, Krieger,
College of I'hysiciuis of Pbila.," 1898.

no PREGNANCY,

or who have reached middle age. Hirtzmann^ found that, of
35 cases, 25 occurred in women over twenty-five years of age.
As an exception to this rule, Strieker ^ reports a case of pre-
cocious menstruation in a child who in her ninth year gave birth
to a true vesicular mole. In 100 cases collected by Dorland,*
68 occurred between the twentieth and fortieth year. It is
hardly necessary to state that cystic degeneration of the cho-
rion villi is necessarily a result of impregnation, and can not occur
in a virgin uterus. Cystic degeneration of the chorion will
often occur in women who have previously given birth to healthy
children, but it will not infrequently recur in the same individual.
Depaul * mentions a woman who had this aflfection three times,
and Mayer ^ has observed the disease in eleven successive
pregnancies. The degenerated chorion usually determines the
expulsion of the ovum at some period between the third and
sixth months of gestation.^ If, however, the disease does not
begin until after the villi of the chorion la^ve have atrophied, or
if the degeneration is confined to a comparatively limited area
the pregnancy will usually go on to term. On the other hand
if the embryo is absorbed and the chorion becomes adherent to
the uterine wall, the pregnancy may be abnormally prolonged to
twelve or thirteen months (Schroeder). The adhesion of the
cystic villi to the uterine wall has more serious results, however
than the mere prolongation of pregnancy. It is often due to the
perforation of the uterine wall by a proliferation of the syncytial
cells of the chorion villi, and consequently when the mass is ex-
pelled there may be fatal hemorrhage from the uterine sinuses
(Volkmann, Waldeyer), or, as in Wilton's case,*^ the peritoneal
covering may be torn and fatal hemorrhage may ensue into the
peritoneal cavity. The retention of a portion of the chorion may
be followed by its decomposition within the uterine cavity, giving
rise to general septicemia ; or fragments of cystic chorion retained
/// litcro may be expelled at a date remote from the original preg-
nancy. With these accidents, of not infrequent occurrence in the
course of the disease, it is not surprising that the maternal mor-
tality is eighteen per cent*

Etiology and Frequency, — The occurrence of vesicular disease

» **Thdsede Paris," 1874.

a Virchow's " Archiv," Bd. Ixxvii, S. 193.

8 "Am. Joum. of Obst.," 1896, p. 905.

* •«Le9ons de Clin. Obstet.," 1872.
' **Tarnier et Budin," p. 306.

« In Borland's 100 cases the mass was expelled in 63 per cent, between the
third and fifth months.

' "Lancet," Feb., 1840.

• Dorland, loc, cit.

THE CHORION. Ill

of the chorion can not be attributed to any single cause. The
connection between disease of the endometrium (Virchow) or
of the uterine walls (fibroid tumor (Schroedcr) ) and vesicular
mole is clearly established in a large proportion of the cases,
especially in those in which there is a frequent recurrence of the
disease ; but this explanation will not suffice for the occurrence
of the disease in the chorion 6f one fetus while that of its twin
remains healthy. In this case the disease is of fetal origin, — ^per-
haps the result of the death of the fetus. Indeed, it has been
claimed that the death of the embryo necessarily precedes the
cystic degeneration of the chorion. That this view is incorrect,
however, is demonstrated by the birth of living children in certain
cases of not too extensive degeneration of the chorion. It has
been claimed also that vesicular mole is the result of an absence
of the allantois (Hecker), or that possibly the allantois may, in
certain cases, contain no blood-vessels (Schroeder), thus depriving
the villi of their circulation.

Stenosis of the umbilical vein has been found associated
with cystic chorion, and, therefore, it has been asserted that the
cystic degeneration may have been due to dropsy of the chorion
villi (Maslowski, Robin). As to the frequency of this affection,
there are no reliable statistics. Mmc. Boivin ^ saw the disease
only twice in 20,375 pregnancies, while in the Charity Hospital
in Berlin it occurred four times in 2130 pregnancies. Two cases
have been under my care in ten years. Every obstetrician of
large practice has seen at least one case. Perhaps once in two
or three thousand cases would be the true expression of the
frequency of this disease.

Treatment. — The treatment of a pregnant woman affected
with cystic degeneration of the chorion is mainly directed
toward the symptoms. Should there be an excessive hemor-
rhage, it might be necessary to timpon the vagina until the os
is sufficiently dilated to permit the expulsion of the cystic mass.
If the diagnosis of cystic disease of the chorion should be made
during pregnancy, and if abdominal or combined palpation gives
no sign of the presence of a fetus, the immediate induction of
abortion would be advisable in order that the chorion might not
have an opportunity to grow to inordinate size and to push its
way, perhaps, into the uterine wall, giving rise to hemorrhage or
possibly to perforation of the uterus. A prolonged retention
of the mass would also predispose to the malignant degenera-
tion of its epithelium. After the expulsion of the diseased ovum,
if there should be symptoms pointing to the retention and decom-

i"Clin. Mem.," 1863.

112 PREGXAXCY.

position of fra<:^ments of the chorion wnthin the uterine ca\'it>% the
natural impulse would be to remove the retained substances;
but it must be borne in mind that the attenuation of the uterine
wall in circumscribed areas may be so great that the slightest
interference, the introduction of a curet, or the administration of
an intra-uterine douche, may cause its rupture with a fatal result*

Fibromyxomatous Defeneration of the Chorion. — If, instead of
being thin and water>% the mucous tissue in the intercellular
spaces of the degenerated villi should contain more fibrous ele-
ments, the resulting mass, instead of being cystic, is solid.
Virchow '^ first called attention to this condition in the placenta
and gave it the name of myxoma fibrosum placentae. In this
case, the first one described, in the midst of healthy cotyledons
one was discovered affected by this fibromucous degeneration.
A similar structure may be found in the peripheral layers of the
umbilical cord.

To complete the study of diseases of the chorion it is
necessar>' to mention a chronic inflammation of the membrane.*
In the case, already referred to, in which the amnion Avas rup-
tured during pregnancy, the irritating effect of the liquor amnii
upon the chorion produced a thickened and hyperplastic con-
dition of that membrane.

THE PLACENTA.

The placenta, as a .separate organ, dates from the third month
of pregnancy. At tiiis time the chorion villi atrophy over the
whole periphery of the o\'um, except at the point where it comes

in direct relation with the true mucous membrane of the uterus

the decidua .scrotina. Here the villi take on an extraordinary
growth, forming buds of epithelial cells (syncytium) upon their
surface, which rapidly take on the shape of new villi, thus send-
ing out branches in every direction, into each of which a loop
of blood-ves.sclf; is projected. Separating the viUi from one
another, and dipping down to the base of the chorion between
the parent stems (^f the villous projections, are processes of the
decidua, carr>'ing capillary' loops of maternal blood-vessels.
Very early in the historv' of the ovum ^ the arterioles of this sys-
tem open directly into the intervillous spaces of the placenta,

» For a case rcsuUinK fatally after the injection of perchlorid of iron, see Priestley,
he. cit.^ p. 41-

» Op. af.,^. 414.

» LebedefT, quoted h\ Tamier, r>/. ri/. , p. 313.

* In Leopold's ovum of 7 to 8 days this arrangement was already visible.
"Uterus u. Kind," Leipsic, 1897.

THE FLACE.VTA. 113

SO that the placenta! villi are bathed directly in maternal blood.
So far almost alt authorities are agreed, but as to the relation
of the terminal villi to the uterine mucous membranes, the action
of the chorional and decidual epithelium, the changes that
convert the uterine capillaries at first surrounding the villi into
the lai^e blood-sinuses that are later found in the placenta.

Fig. 83— Tht

many conflicting theories have been advanced. In regard to the
relation between the placental villi and the uterine mucous mem-
brane, it has been variously stated that the former enter the
• of the uterine glands (BischofT); that they sink into
crypts in the uterine mucous membrane, which are new forma-
tions especially adapted for their reception (Turner) ; that the

114

PREGNANCY.

villi do not sink into glands or crypts, but are intimately invested
with a layer of decidual epithelium, or with an endothelial cover-
ing derived from the maternal blood-vessels (Ercolani) ; and that
this cell-covering acts as a glandular structure, secreting from
the maternal blood a peculiar substance, the so-called "uterine
milk," which acts as nutriment for the fetal blood {Ercolani,
Hoffman). It is now well established, however, that the placental
villi imbed themselves in the soft interglandular substance of the
decidua serotina, and that the connective-tissue cells multiply and
hypertrophy around them (decidual cells). The epithelium of the
uterine mucous membrane disappears, except in the glands. The
chorion villi are at first covered with two distinct layers of cells ;
an inner layer composed of single large nucleated cells arranged
side by side with distinct cell walls (Langhans' layer), and an
outer layer or band of
protoplasm in which
are imbedded nuclei
- -.. at irregular intervals

*yt(} {the syncytium). Both

of these layers are de-
rived from the chorion
and not from the
ute ri ne epithelium.

Fig. 84.— The capillary

a Minot).

I'!!arlj- in embryonal
life (the third month)
the langhans' layer
disappears and the
syncytium remains as
the sole epithelial
covering of the villi.
The uterine mucous
membrane at first
is richly supplied with capillary blood-vessels, from which
loops are thrown around the villi in such fashion as to form a
complex but very distinct network throughout the placental
mass. I-ater these capillaries disappear, and in their place are
seen the large sinuses or lacunx, to which blood is conveyed from
the maternal circulation by little curling arteries that wind their
way up through the decidual cells and empty directly into the
placental sinuses. These arteries are provided with only a deli-
cate endothelial wall. From Leopold's ' observations it appears
that the arterioles of the decidua become more and more dis-
tended as they approach tJic placental viUi, so that their terminal

THE PLACEXTA.

Fig. 85-

genentiied Tonn :

■e of pl»cenU of

^ Placenta in its

. „ . , ! of placenta of . ,

of placFHlB of cat 1 F, structure of plHcenta of sloth \ on the right side of the figure

the flit tnnlTmal epithelial cells are shown in situ ; on Ihe left side tbcy are rcmaved,

and the dilale<l malcmal vessel with its blood-corpuscles is exposed ; G, structure of

hsman pinccntai E, tela\, and Af. maternal placenta; e, epilheiiutn of cborion ;

-'. epilheliura of malernal placenta -. li, fetal blood-vessels ; </', maternal blood'

b1»1 f.Tilllu. The »ucceeding rfftcrences apply lo Gonlj: rfj, Decidua serotma

'Cenla; t, trabecule of serotina passing lo fetal villi) ea, curling Bitery

lacenlal vein (from fialfour, after Turner).

Ii6

PREGNANCY.

expansions may be compared to a sea into which project penin-
sulas and capes of decidual masses and placental villi. The
syncytial cells of the latter have the power to penetrate the
endothelium of the decidual arterioles and thus open a direct

THE PLACENTA. I17

tlie capillary system of the villi ; the latter bathes the exterior of
" e villi.

The Fully-developed Placenta. — The placenta at term is
a circular mass, measuring about seven inches in diameter.
about two-thirds of an inch to an inch in thickness at the point of
insertion of the cord, and weighing about sixteen ounces. Upon

PXECNJA-CV.

extent, — the cotyledons. Over the maternal surface of the pla-
centa is stretched a delicate, grayish, transparent membram;.
which is made up of the cells that compose the upper layer of the
decidua scrotina. This constitutes the maternal portion of the
placenta, lii scjiarating from the uterine wall, therefore, the line
of so|)aration does not divide the fetal from the maternal struc-
tures, but is found in the mucous membrane of the uterus, in tlie
lower portion of the cellular layer of the decidua. Around the
periphcrj' of the placenta may be seen a large vein, the circular
vein of the placenta, which returns a part of the maternal blood
from the organ, the remainder returning to the maternal circula-
tion by mean.s of the continuity between the placental lacunx
and the uterine sinuses. The situation of the placenta within the

the fifth month: Ck, Chonon;
smflll arteries 1 /, gtandn-

uterus may with equal frequency be found either upon the poste-
rior or the anterior wall ; occa.sionally. however, upon one of the
lateral walls, more frequently the riglit (Schroeder).

A peq^endicular section through the middle of a placenta
that is .-itill attached to the uterine wall reveals an intimate
connection Ixtween the two. The delicate terminal villi and
even bnmclies a millimeter in thickness, are imbedded in the
np]XT portion of the decidua, and lield in place by their
extri'mities bulging out into club-shaped masses, so that tlie
exercise of considerable force will not extract them from the
uterine mucous membrane, but will, instead, always lacerate
the maternal structures.

The functitins of the placenta are manifold. Not only does it

THE PLACENTA. 1 19

act as a lung, or, rather, gill, in oxygenating the fetal blood, but
it may be said to take the place of the alimentary tract in ab-
sorbing nutritive material from the maternal circulation. It is
probable, moreover, that it plays the part of an excretory organ,
getting rid not only of the surplus carbonic oxid gas in the fetal
blood, but also of the other waste-products of a tissue-activity
that in the rapidly growing fetus must be great. Bernard has
shown that in the earlier months of pregnancy the placenta has
a glycogenic function. The epithelial cells of the chorion villi
take something more than a passive part in the passage of
substances to and fro between the fetal and the maternal blood.
They have a certain power of selection or resistance. Some
pathogenic micro-organisms — as, for instance, those of variola —
pass easily from mother to fetus, while the bacilli of tuberculosis, a
disease often present in pregnant women, are almost never found in
the fetus. Certain drugs, also (iodid of potassium, benzoic acid,
bichlorid of mercury), enter the fetal from the maternal blood,
while it is asserted that others, as woorara, will not pass to the fetus
from the mother. Again, while nutritive material must pass from
mother to fetus, the escape of the same material from the fetal
into the maternal blood would prove destructive to the fetus.

Anomalies of the Placenta. — The placenta may present de-
viations from the normal in size, position, shape, weight, or num-
ber. Its structure may present anomalies the result of diseases
or accidents, and there may be anomalies of function.

Anomalies of Position, Size, and Weight. — The position of the
placenta is normally near the fundus uteri. A low insertion gives
rise to the condition known as placenta prcevia, which will be
more fully described in its appropriate place. The size of the
placenta may vary considerably. The thickness of the organ is
in inverse ratio to its extent, and the younger the ovum, the
greater is the relative size of the placenta. The placenta, instead
of being confined to that portion of the ovum which is in contact
with the decidua .serotina, has been known in rare cases to extend
around its whole periphery. This condition is known as placenta
membranacea, and is to be explained, of course, by the equal
development of all the chorional villi. On the other hand, the
placenta may be abnormally thick and enlarged in all directions,
owing to an irritation from a chronically inflamed endometrium,
which results in a hyperplastic condition of both the maternal
and fetal portions of the organ. An abnormally small placenta
may be associated with an ill -developed child, may depend
upon an interstitial overgrowth with subsequent retraction, or
may be due to atrophy of the decidua.

Anomalies of Shape and Number. — The placenta, usually round

120 PREGNANCY,

or oval, may have a horseshoe or crescentic shape, especially if
it is inserted near the internal os, which in these cases is sur-
rounded by the two arms of the crescent. In multiple preg-
nancies each child has its own placenta (Fig. 91). A single
child may have two (placenta duplex), three (placenta tripartita),
or more placenta; (placenta multiloba), or a single placenta may
be reinforced by one or more small accessory placental develop-
ments (placenta; succcnturiata;), which are in direct communication
with the blood-sinuses of the decidua vera. Should the villi of
these accessory growths not communicate with the maternal
blood, the growths are called placentze spurise. Taurin • has
reported a case of annular placenta, extending almost completely

around the ovum as it does in some animals, but separated indis-
tinctly into three lobes.

Bdema of the PIscentn. — A serous infiltration of the whole
placenta is often observed with a dead and macerated fetus.'
The same condition is often associated with general anasarca of
the fetus, with some ob.struction of the umbilical vein or of the
venous system of the fetus, or with a greatly hypertrophied pla-
centa which absorbs more fluid than tlic fetal economy can dispose
of (Werth), The minute anatomy of the placenta may remain

' •■ Nonv. Arch. H'Olistil.." 189.1. p. 486.
* Tunier et lludin, ap. tit., p. ji^.

Anomdiu uf the Plnccola : I, Itucenla wilh imgiilBr lalies (Auvnrd) ; I, placenu in
two imeqiwl lobc& (Aavud) : 3, icregulnr iilaccnla (Auvstd) ; 4, small accessory plBcentB
(Ribemont- Lepage I ; 5, placenta succenturiala (Riberaonl-Lcpage) ; 6, " liiillledoie "
placenl*, oval (AuTard) ; 7, placenta with velainentiius allachmcnl of cord (Ribemoat-
Lcpage) ; 8, placenta with two equal bbes (RibeoiDnt- Lepage).

lemoDt- ^^t

THE PLACENTA. 121

normal in this disease and the placenta may continue to perform
its physiological functions.

Degeneration of the Placental Villi. — ^The morbid processes that
result in such grave alteration in the structure of the placental villi
as to abrogate their physiological activity are, hypertrophy, fibrous
and fatty, caseous (phthisical placenta), calcareous, and myxoma-
tous degenerations. Placental hemorrhages, placental syphilis,
and solid tumors of the placenta have, as a result, the destruction
of all or of a part of the placental villi as factors in the nutrition
and aeration of the fetal blood, but these conditions will be con-
sidered separately.

Cellular Hypertrophy. — Ercolani ^ has described, under the
name of ** cellular hyperplasia and hypertrophy of the paren-
chyma of the placental villi," a disease that is characterized by
the extensive multiplication of the cellular elements in the villi
to such an extent as often to obliterate the blood-vessels and
to give the placenta a hard, dense appearance and feel that has
been called by other writers sclerosis of the placenta, and has
been attributed to the overproduction of fibrous tissue. Cellular
hypertrophy may also be seen in syphilitic disease of the villi.

Fibrous and Fatty Degeneration of the Plaeenta. — A fibrous
and fatty change in the placental villi is extremely common, and
isolated examples of it may be found in almost every placenta,
especially toward the periphery of the organ. It is necessary to
consider the two together, for they are always found in common,
except when the degeneration of the placenta follows the death
of the fetus. In this case there is a simple fatty change without
other pathological process (Barnes). It has been claimed by
some observers, as Barnes^ and Kilian,^ that fatty degeneration
of the placenta may be the primary pathological process, and
may originate independently of other degenerative changes ; and
it has also been asserted that this degeneration is only an exag-
geration of the condition that normally obtains in the placenta
toward the end of pregnancy ; but most modern investigators
agree with Robin and Ercolani that the fatty change is sub-
sequent to other degenerative processes, most frequently an
abnormal development of fibrous tissue, — a condition that might
be termed interstitial placentitis. This development of fibrous
tissue must be distinguished, however, from the fibrous change
that occurs in blood-clots due to effusion from the maternal
capillary loops in early pregnancy, or to thrombosis in the pla-
cental lacuncC later on. The fact that an inflammation of the

* "Dellc Malaltie della Placenta," Bologna, 1871.

« «* Med.-Chir. Trans.," 1851.

» "Neue Zeitschr. f. Geburts.," 1850.

122 PKEGXAXCY.

placenta can occur has been denied. There are, however, the
same multiplication of connective-tissue cells and a subsequent
contraction that one sees everywhere in the body in a chronic
inflammation.

The fibrous change may originate either in the decidua sero-
tina, the placental villi, or the intervillous spaces.

If the disease affects the decidua serotina, it is associated
with chronic inflammation of the remainder of the endometrium,
and it would be better, perhaps, with Braun, Schroeder, and
Spiegelberg, to regard it not as a disease of the placenta, but
as an endometritis. As the disease progresses, however, the
placenta becomes secondarily involved, either by the encroach-
ment of the hypertrophied decidua upon the intervillous spaces,
and the consequent compression of the villi, or by the agglutina-
tion of the ditTcrent layers of the membrane one to another,
which may result in a firm adhesion of the placenta to the
uterine wall. Hegar and Maier and many others have de-
scribed tills disease as interstitial endometritis.^

The same microscopic appearance may be seen in a hv^jer-
trophicd decidua throughout its extent, and is not confined to
the placental site. It is, however, possible to find an endome-
trium in an advanced stage of hyperplastic inflammation, while
the upper la>'er of the decidua serotina remains unchanged even
although the placental site itself is immensely thickened by new-
formed connective tissue and enlarged blood-sinuses. In such a
case the placenta remains unaffected.

The fibrous degeneration may have its seat in the placental
villi alone. The process that transforms a healthy villus contain-
ing blood-vessels into a bundle of connective tissue can well be
studied in the extraplacental villi of the chorion, which normally
undergo a fibrous degeneration, as they begin to atrophy at the
third month of pregnancy. The mucous tissue in the interior
of the villi is converted into fibrous tissue, the blood-vessels
are obliterated, and the villi shrink, atrophy, and become more
or less infiltrated with fat. This same process may be seen in
isolated villi of almost every placenta. If the process becomes
more extended, the functions of the placenta are naturally abro-
gated. According to Neumann, ^ the interchange between fetal
and maternal blood may be prevented by the great hypertrophy
of the placental villi and their consequent encroachment upon
the maternal blood-spaces.

The development of connective tissue may take place in the

1 Virchow's " Archiv," 1871.
» See Priestley, he. cit. , p. 54.

THE PLACENTA. 1 23

intervillous spaces, — a condition to be distinguished from the
fibrous mass that results from the effusion of blood or the
occurrence of thrombosis in the same situation. The develop-
ment of the fibrous tissue has been ascribed by Simpson,
Rokitansky, Scanzoni, Priestley, and others to an inflammation
followed by a cellular exudate which organizes into connective
tissue. Priestley has described, under the name of placental
phthisis, a pathological condition of the placenta brought about
in this way : The first stage of the disease consists of an exuda-
tion or deposit thrown out among the villi, probably due to some
modification of a low inflammatory process, the result of which
is a sort of ** hepatization " of the part affected. The mass thus
formed either remained dense and firm throughout, or else in the
center might be found a crumbled and disintegrated substance
resembling the result of cheesy degeneration of tuberculous
masses in the lung. As a result of this disintegration there may
be found evidences of old hemorrhages in blood-clots at different
stages of organization.

The result of fibrous degeneration of the placenta, wherever
the disease originates, is to prevent the performance of its most
important vital functions, and if the pathological condition in-
volves a large area of the organ, it must prove destructive to the
fetus. The deprivation of their blood-supply determines the
fatty degeneration, or in some cases amyloid degeneration, ^ of
the placental villi. This fatty infiltration is the more marked, as
a rule, the older the original lesion. Thus, Bustamentc's ^ de-
scription of a '* sclerotic " placenta as presenting a reddish, spotted,
lobulated, or smooth mass resembling the thymus, would be
applicable to a fibrous placenta, in which fatty degeneration had
not advanced very far. In the latter case the organ would pre-
sent a paler, yellowish hue. The diagnosis of fibrofatty degen-
eration of the placenta is impossible during pregnancy. Such a
condition may be inferred if there is a history of previous
repeated occurrences of the disease.

Myxomatous Degeneration. — The myxomatous degeneration
that has already been studied in the chorion villi maybe confined
to the placenta, while the extraplacental chorion remains healthy.
Myxoma fibrosum placentae has already been described. This
affection has been observed by Virchow,^ Storch (two cases),"*
Hildebrandt,^ and Sinclair.^

* Green, " Am. Jour. Obstet.," 1880, p. 279.
«**Thdsede Paris," 1868.

• Loc. cit.^ p. 414.

* Virchow*s "Archiv," 1878 ; and Breus' " Wien. med.Wochens.," 1881, No. 40.
» "Monat. f. Geb.," Bd. xxxi, S. 346.

• "Jour. Obstet. Soc," Boston, 1871.

124 PREGNANCY,

Calcareous Degeneration. — Depositions of small quantities of
lime in the placenta are not at all uncommon. They are usually
to be found in that portion of the maternal placenta lying nearest
the villi, or they may originate in the villi themselves. Cham-
bord ^ has found as many as five hundred concretions in one
placenta. It has been said that extensive calcification of the pla-
centa is more apt to occur after the death of the fetus, but Tar-
nier asserts that there is no relation of cause and effect between
the two, and that the occurrence of large calcareous deposits in
the placenta with still-born children is a mere coincidence, as it
is also in those cases in which calcareous degeneration is asso-
ciated with syphilis. 2

Placental Syphilis. — From the end of the last century, when
Astruc first called attention to the fact that syphilis of either
parent was apt to result in the birth of still-born and macerated
children, until the appearance of D'Outrepont's paper ^ in 1830,
the opinion prevailed that the cause of the repeated fetal deaths
must be sought for in syphilitic disease of the viscera. It was
the last-named author who first called attention to the influence
of the diseases of the placenta upon the nourishment and the life
of the fetus. Shortly afterward followed Simpson's well-known
work,"* and ever since all pathological conditions of the placenta
have been investigated with increasing care, and the changes asso-
ciated with syphilis have received special attention. Virchow
was the first to divide the study of placental syphilis into the in-
vestigation of the lesions in the maternal and in the fetal portions
of the organ and to consider apart the changes in the decidua
serotina (endometritis placcntaris gummosa) and those in the
extraplacental decidua (endometritis decidualis). No consider-
able advance was then made in the knowledge of placental
syphilis, although the subject was investigated by many ob-
servers, until Slavjansky and Kleinwachter ^ called attention to
the development of fibrous nodes "of a syphilitic nature*' in the
fetal portion of the placenta and to the degeneration of the epithe-
lium in the placenta materna. In 1873 appeared FrankePs
paper in which he claimed to be the first to demonstrate that
the '* deforming granular hyperplasia and hypertrophy of the
placental villi," already described by Ercolani, — without, how-

1 ** Lyon M6dicale," 1873, P- 43i-

a See also Frilnkel, " Archiv f. Gyn.," Bd. ii, S. 373; Winckler, "Archiv f.
Gyn.," Bd. iv, S. 260; Langhans, **Archiv f. Gyn.," Bd. iii, S. 150.

* <( Ueber die Krankheiten u. Abnorm. der Placenta," ** Gem. Deutsche Zeitschr.
f. Gcl>urtrfi..»» Bd w -^

" ^ Sci.," Feb., 1845; "Obstet. Works," vol. ii,

Syphilis," " Archiv f. Gyn.," Bd. v, S. 6.

THE PLACENTA.

125

ever, reference to its connection willi syphilis, — was the most
Trequent fonn of placental syphiUs.

According to Frankel.this infiltration of the vilU with granu-
lation-cells, and their consequent increase in size and distorted
shapes, are characteristic of syphilis and make certain the diag-
nosis of the disease. As to the scat and extent of the lesion, they
vary with the manner and time of the fetal infection. If the
ovule is infected by the impregnating spermatic particle, the
placenta, if diseased at all, will constantly present the granulation-
cell infiltration of the villi and the degeneration of their epithelial
covering- If the mother is infected during the fruitful coitus, there

tdometritis placenlaris characterized by the enormous

Fig. 92. — Section of villi, showing small cell infill mlion and ihe defonoed hhapea
of villi; A.A, Lunuriaineell-devclopment in the interior; J', (', lumen of blood-vessels
wilh hypertrophied walls ; £, villus in wbicb odIt a trace of blood-vessels can be <<eeii al
S; C.,C, villi without trace of vascular canal ; D,D,D, epithelial covering (Fiilnkel).

overgrowth of the decidual cells or the overgrowth of connective
tissue as well as syphilitic disease of the villi. If the mother is
syphilitic before conception, the disease of the placenta takes tiie
form of endometritis placentaris gummosa. If the mother is
infected during the latter months of pregnancy, the placenta usu-
ally remains unaffected. Frankel bases these conclusions upon
the examination of more than one hundred specimens, and his
views have been conlirmed by Hennig ' and MacDonald.'
Specimens of syphilitic placentEe in my possession show the

"Archivf- Gyn.,'

r. Med. Jou

" Aug., 1875, p. 2J4.

1 26 PREGNANCY.

condition of the villi described by Frankel, and also an endome-
tritis placentaris gummosa, in which the decidual cells are enor-
mously increased and overgrown, encroaching deeply upon the
intervillous spaces and undergoing degeneration in places. In
one case, in which the mother was infected at about the fifth
month of pregnancy, the placenta matema at birth «-as greatlj-
thickened, and showed under the microscope an extraordinary
development of connective tissue. The fetal placenta and the
child itsc'lf were i>crfectly healthy.

In their macroscopic appearances syphilitic placenta mav
differ considerably. If the child has been dead some time, the
placenta may be almost white in appearance and soft and greasy
in feel. 1 If the child
is expelled alive at
term, the placenta is
often unusually large
and of a pinkish color,
due to the thickened
decidua. which pre-
vents the true color of
the organ from ap-
pearing. Very often
there are oi^anized
clots, showing a pre-
vious hemorrhage into
the placenta or the
occurrence of throm-
bosis in the lacuna;
Fig. 9j,-Syi)i,imic di,ca-,- „f lUo [ilacema, siionine °'' ^'^ there may be
Kraiiki.-|-> dUi^aaf. found nodes^ of a

greater or less extent,
lamcllated in structure and undergoing degenerative changes in
the central portions. Often, too, there is extensive calcareous
degeneration.

The consequence of syphilitic disease of the placenta is
usually disastrous to the fetus and often dangerous to the mother
The cellular infiltration of the villi obliterates the blood-vessds
within them, and consequently abrogates their functions. The
same effect may be produced by the hyperjjiasia of the decidua
scrotina and the consequent encroachment of the decidual tissue
upon the intervillous blood -.spaces, or the destruction of the villi
may be brought about by the formation of the. nodular masses
that have been noticed. All these processes, if. as is the rule,

1 ninr[ienlkr, " -Sjph. htriditaire," 1870, " Presae Mftd. Beige," No, 8.
» Ziller, •' Studien Qber Erkrankungen der Placenta," etc., Tubingen, 1SS5.

THE PLACENTA. 12/

they invade the whole area of the placenta, must, of necessity, be
fatal to the fetus. The endometritis placentaris that is often a
prominent feature of placental syphilis may prove dangerous
to the mother by so matting the layers of the decidua serotina
together as to occasion a close adherence of the placenta to the
uterine wall, thus subjecting the woman to the perils of hemor-
rhage, septicemia, or inversion of the uterus that are incidental
to adherent placentae.

The accurate diagnosis of placental syphilis is impossible
during pregnancy. The condition may be inferred with con-
siderable certainty, however, should a history of syphilitic infec-
tion be obtained from either parent.

The treatment will be referred to later under the head of
Fetal Syphilis.

Placental Hemorrhages. — The term placental hemorrhage is
used to indicate circumscribed collections of blood that have
undergone more or less change, frequently found in the placenta.
The blood may be found in the shape of a fresh clot, sometimes
occupying a very large area, especially in those cases in which
abortion occurs as a result of the premature detachment of the
placenta ; or the extravasated blood may be encapsulated, sur-
rounded by a fibrous wall of varying thickness, within which
may be found a reddish or a brownish fluid ; or the cyst may
contain nothing but clear serum, while the coloring-matter of
the blood is deposited upon the cyst-wall or upon the surround-
ing villi. ^ The encysted hematocele, on the other hand, may
contain large numbers of white blood-corpuscles undergoing
fatty degeneration, giving rise to a liquid resembling pus. It is
such cases, according to Tarnier, that have been described as
abscesses of the placenta by Brachet, Cruveilhier, O'Farrell, and
Simpson.

Again, the fibrin may predominate, especially in those cases
of thrombosis in the placental sinuses described by Bustamente^
and Slavjansky,^ when, if the clot is slowly formed, the resulting
mass will consist of laminated fibrin, such as one sees in aneur-
ysms undergoing obliteration. In other cases the serum is
rapidly absorbed, and there is left a mass of red globules con-
taining white corpuscles, either heaped together or scattered
through the mass. . Finally, the clot may organize through the
process described by Weber and confirmed by Virchovv, and

* Ercolani has descril)e(l a case of ** placental melanosis" in which there was no
trace of blood-extravasation, but the villi were infiltrated with pigment-granules
(" Archiv de Toe," 1896, p. 193).

^ Loc. cit.

» " Archiv f. Gyn.." 1873, Bd. v, 360.

1 28 PREGNANCY,

thus form a distinct neoplasm in the placenta. The placental
villi surrounding the extravasated blood usually undergo a fibro-
fatty change.

The causes of placental hemorrhage are manifold. The pre-
disposing causes may be stated to be those that lead to apoplexies
elsewhere in the maternal system, as congestions (Simpson) or
albuminuria (Winter, Fehling) ; the slow-moving blood-current
in the placental sinuses and the excess of fibrin in the blood of
pregnant women, predisposing to thrombosis (Bustamente) ; aiid
diseased conditions of the placental villi (Charpentier and others).
The determining cause may be a sudden, powerful action of the
heart, producing at the same time, p>erhaps, apoplexy of the
placenti and of the brain ; or syncope, favoring the formation of
a thrombus ; or external violence. In the early months of preg-
nancy it is more frequently a true apoplexy that gives rise to the
hemorrhage, from rupture of the delicate capillary loops of
maternal origin that surround the villi. ' Later, it is more frc-
cjucntly thrombosis in the sinuses, or the laceration of the deli-
cate blood-vessels that perforate the upper layer of the decidua
serotina t() enter the placental sinuses. ^

The consequence of placental hemorrhage to the fetus de-
jxinds upon the amount of blood extravasated. Should the
quantity be lari;c, cither the number of villi strangulated by the
clot is so great that the fetus is at once asphyxiated, or else the
escaping blood is able, especially in the earlier months, to strip
the placenta off tVcMii the uterine wall, with the same result. The
effect of placental hemorrhage upon the mother is usually unno-
ticeable, except in case the fetus is killed, when the whole ovum
will be prLMiiaturely expelled. In some instances, however the
blood forces itself between the i)lacenta and uterus, and bur-
rowing its wa\' downward through the layers of the deciduae
makes its appearance externally as a hemorrhage from the
uterus. Or else the blood, unable to escape, will collect at the
placental site, or possibly ov^er a larger area, sometimes in such
quantities as to form distinctly an additional tumor of the uterus
appreciable through the abdominal walls, and also to give rise to
all the symptoms of internal hemorrhage.

Placentitis — An interstitial placentitis has already been de-
scribed. Older authors paid particular attention to inflammations
of the placenta, and Simpson described three stages of the dis-

* My friend. Dr. Rol>ert H. Hamill, of Philadelphia, has shown me a specimen
exhibiting an interesting variety of placental hemorrhage. Immediately beneath
the amnion there was a large clot occupying more than half the area of the placenta,
and evidently containing all the bloo<i of the fetal Ixxly. The fetus, corresponding
in development to the fourth month, had bled to death into its own placenta from the
rupture of a large branch of the umbilical vein.

THE PLACENTA, 1 29

ease — ^the first characterized by congestion, the second by plastic
exudation, the third by suppuration. Numerous instances have
been recorded in which " pus " was found in the placenta, but the
majority of the cases reported will not bear modem investiga-
tion. There are, however, authentic instances of such an occur-
rence.^

Cysts of the Placenta. — Cystic formations may be found not
very infrequently in the placenta. In the majority of cases they
are the result of changes in extravasated blood. They are
sometimes, however, to be ascribed to a circumscribed, un-
usually fluid myxoma. 2 Jacquet ^ has described small cysts
springing from the blood-vessel walls.

Tumors of the Placenta — ^The tumors of the placenta formed
in the fibromyxomatous degeneration of the villi have already
been noticed. Organized blood-clots have also been described
as tumors of the placenta. Hecker ^ speaks of a fleshy sub-
stance expelled from the uterus post-partum, although the pla-
centa had come away entire as possibly a placental tumor. This
may, however, have been nothing but a uterine polypus or a piece
of hypertrophied and angiomatous serotina.^

Malignant growths at the placental site have long been recog-
nized as malignant placental polypi. In 1888 Sanger described
a sarcoma of the decidua serotina. His article attracted great
attention and was immediately recognized as most important
both in the nature of the tumor described and in its histology.
The attention of physicians all the world over being directed to
the matter, malignant tumors of the placental site were found to
be not so exceedingly uncommon. The author saw two in three
years. It was soon realized, however, that the majority of the
growths observed were carcinomata and not sarcomata, and a
close study of their histology soon demonstrated the fact that
the cancer has its origin in the syncytial cells of the chorion villi.
Even in the metastases the syncytium of the placenta is every-
where reproduced. From recent sections of the original tumor
studied by Sanger, it appears that it really was a sarcoma. It is
now admitted that both sarcomata and carcinomata may develop
at the placental site, the former from the decidual cells (deciduo-
sarcoma, deciduoma malignum), the latter from the syncytium
(carcinoma syncytiale, syncytial cancer). Cancer of the placental
site, however, is much more common than sarcoma. Gaylord

* See Schroeder, " I^hrbuch," ed. of 1884, p. 450.
« " Archiv f. Gyn.," Bd. xi. S. 397.

» "Gaz. in*d. de Paris," Oct. 14, 1871.

* " Klinik der Geburtsh.," 1864.

* Sec paper by the writer in •* Am. Jour. Obstetrics," Dec, 1887.

I30 PREGNANCY.

has collected fifty -five reported cases. ' Both of these malignant
growths have a rapid course, ending fatally in from three to six
months. Metastases are numerous and occur early. A metastatic
growth of syncytial cancer is possible without a trace of the ori"jnaI
tumor. Schmorl * reports a syncytial cancer of the vagina witli
numerous metastases, the uterus being healthy. It i.s supposed
that the original growth was removed with the exfoliation of the
decidua serotina. Other tumors of the placenta are mj-xomati
fibrosa, localized hypertrophies, angiomata,^ and organized throm-

f'isrs''p^^ '^ ' -t

i"'

-;>, ' U: /

>'-•]*« ■•• ■

^ ^ Y^'f^ 1 *

■lu! '^"'"""'"'^ islanda of prolifcrticd

boses. Bode and Schmorl * report as a tumor of the placenta
(fibroma) a fibrous degeneration of a placenta succenturiata Tho"
have collected the reports of thirty placental tumors. Albert {/iv
cit.) adds si.x cases to their list. Placental polypi developing on the
placental site after labor are due to a sort of stalactitic disposition
of blood-fibrin on a mass of decidua or a fragment of placenta.

' " Tr. of Ihe Sfclion on <.;>-n.," College of Physicians of PhiladelBhia iJtnS.
" " Centralbl. f Gyn.," 1896. "^ ' ^^

» Albert, " Archiv f. Gyn.," Bd. Ivi, H. I, p. 144.
«"ATCbivf. Gyn." Bd. Ivi, H. 1, p. 73.

THE PLACENTA.

Fig. 95.— Syncytial cancer (Gotlschalk).

Localized tumors in the placenta are rare, Leopold in more
than 7000 specimens found such a tumor only once.'

'V. Man, " Monatschr. f. Geburtsh. u. Gyn,," Bd. it, H. 3, p. 239.

PREGNAiWCY.

THE UMBIUCAL CORD.

Tile early development of the umbilical cord, or the formation
of the allantois, has been studied upon the lower animals, as in
all the human embryos observed the connection between the
embryo and the chorion was already established. Indeed, accord-
ing to His, the human embryo is from the first in connection with
the periphery of the ovum. Very early, therefore, in embryonal
life there may be observed a sac -like projection from the posterior
end of the intestinal tract, which, at first solid, but later contain-
ing a canal, grows outward and backward, owing to the presence
of the large umbilical vesicle anteriorly, until it comes in contact
with the periphery of the ovum. Within this sausage-shaped •

P«»

Fig. 97- — A, L'mliiticnl orleries forming spirals (i, i) around the vein ; con-
ictions indicaiinE Ihe presence of folds (i/, f)\ circuloi folds (d, t); lalcml
openings showing the antTial walls ; B, vein o|ienF(l upon the side showing a con-
striction (d) corresponclinfi to an interior valve (c) ; semilunar valves (r, d, <■);
C, section of vein and arteries showing valve of vein (a), a semiiuDor arterial valve
{b), and n circular arterial valve (.} (Tnrnier et Chantreuil).

projection are blood-vessels, which arc carried with its growth
to the periphery of the ovum, where they enter the villi oPthe
chorion in the manner already described. Ilecoming reduced
to two arteries and a vein within the allantoi.s itself, they con-
stitute the vessels of the umbilical cord, which are destined
to carry the blood of the fetus to the placenta for aeration and
nourishment, the two arteries conveying dark, venous blood ;
the vein returning bright, oxygenated blood, resembling in this
respect the pulmonary arteries and vein. Surrounding the blood-
vessels of the cord is a peculiar gelatinous substance, furnishing
the vessels the most perfect protection possible under the cir-
cumstances (lliu .so-callL'd gelatin of WlLLrlmi 1, ilciiMil from
the outer layers of the amnion and the all;ititins, both in their

THE V.MBJUCAL CORD.

"33

turn being derived from the median layer of the blastodermic
membrane. As the amniotic cavity becomes distended the
amnion is pushed out on all sides until it meets in front of the em-
bryo, and surrounds the cord like the finger of a glove, at tlie
same time inclosing tlie already atrophied umbilical vesicle, the

— A, Section of Ihe navel : C, Outer covering wilh blood-vessels; I'.u.,

i; ii.H,, ii.H., umbilical artery : I'.i'., otnphnlicduct; »., remnant of the

\'.S., bbtalh of the conl. Uthcr Icrllcring u in A.

ductus omphalicus, and the pedicle of the allantois. That por-
tion of the allantois that remains within the abdominal cavity of
the fetus forms the bladder and urachus. The umbilical cord at
term measures about 50.8 cm. (30 in.) in length and about 0,9 to
1.3 cm. {y^ to Yi in.) or more in
diameter, the latter measurement
being irregular, from the fact that
the arteries are coiled around the
vein, usually from right to left,
giving a twisted apjiearancc to
the cord, and also because the
gelatin of Wharton is deposited
irregularly, being in some places
quite thick, and forming thus the
so-called false knots of the cord.
Both the arteries and the
veins of the cord have walls of
almost the same thickness, and
both are provided with semi-
lunar and circular valves. The

caliber of the vein is greater than that of the arteries. According
> Leopold,' it measures normally 2 to 4mm. (0.079 too.157 '».)
^^' T, but at a point about 8 to 10 cm. (3.15 to 3.94 in.) from

1 insertion there occurs a physiological narrowing.

Archiv f, Cyn,

FiB

09—

Cross-

action of

in urn-

biticol c

jrd a

about

t»e!ve A

nmelcT!: Y

Remnant of the

illanlois

UQibilicsl vein;

A,A,

umbilical

arterr

M(flO

n Hinol).

134 PREGNANCY.

Anomalies of the Cord.— The cord may be abnormally
long, measuring rarely as much as 70 inches (178 cm.), ^ or it
may be naturally or artificially too short ; and it may be absent
altogether. The cord is artificially shortened in those adhesive
inflammations of the amnion which result in the gluing together
of the coils or ill their altachmenl to the fetal skin or amnion.

Exaggerated Torsion. — Tiie cord may be so twisted upon its
longitudinal axis that the vessels are nearly or quite obliterated,

and the cord itself, cspeciaily near the umbilicus, is reduced to a
very small diameter. Formerly the torsion was regarded as a
cause of fetal death, but Martin, Ruge. Schauta, and most modem
observers regard the exaggerated torsion of the umbilical cord
as a postmortem occurrence, resulting from the great movability
'^' of a fetus that has died from the fifth
' pregnancy. The number of twists in

THE UMBILICAL CORD. 1 35

the cord may be surprisingly great. In Schauta's ^ case it reached
380. Torsion occurs more frequently in male than in female
children. Edema and cystic degeneration of the cord may often
be found in connection with exaggerated torsion.

Stenosis of the Umbilical Vessels. — The umbilical vein may
be narrowed by the development in the intima of new connective
tissue ^ to such an extent as to seriously impede the flow of blood
from the placenta, — a condition resulting in edema of the latter
organ (hydramnios), or an immense dilatation — to 15 mm.
(0.6 in.) — of the undiseased portion of the vein, ending occa-
sionally in its rupture (Leopold) and the extravasation of blood
into the substance of the cord. This disease of the vein is
usually attributed to syphilis. A periphlebitis may also occur,
and may diminish somewhat, but not seriously, the caliber of
the vein. The umbilical arteries are occasionally obstructed by
atheroma and thrombosis.

The section of an umbilical cord taken from a syphilitic in-
fant sometimes shows an enormous development of connective
tissue throughout the entire wall of the arteries, so that it is
impossible to distinguish the different coats ; the lumen of the
vessels is often obliterated, not only by the thickened walls, but
by the infiltration of the whole substance of the cord with granu-
lation-cells. Pinard^ has seen the vessels of the cord obstructed
by an overdevelopment of the valves that are found in both
arteries and veins.

Varices and Rupture of the Vessels in the Cord Figure

10 1 represents a varicose condition of the vein of the cord which
predisposes to rupture. Five cases of this accident have been
collected by Albert.^

True Knots of the Umbilical Cord. — Rarely the fetus slips
through a loop of the cord, and, the two ends of the loop being
then put upon the stretch, a true knot is tied. This process may
be repeated either during pregnancy or while the child is descend-
ing in labor, and thus a double knot is tied. In the cord of an
infant born under my care there was a true figure -of-8 knot
tied m utero (Fig. 102). In the case of twins in a common
amniotic cavity the most complicated knotting of the two cords
may occur. The effect of these knots in the cord upon the cir-
culation of the fetus is usually not serious. Carl Braun ^ says

* Leopold, •• Archiv f. Gyn.," Hd. xvii, S. 20; see also Winckel, '* Berichte u.
Studien."

* •* Neue Zeitschr. f. Geb.," Bd. iv, S. 62 ; and Leopold, he. cit.

* *• Diet, encyclopid. des Sc. med.," art. *• Fetus."

* ••Archiv f. Gyn.," Bd. Ivi, H. i, p. 136.
» •« Lehrbuch der Ges. Gynak.," p. 552.

136 PREGNANCY.

that he has never seen the slightest disadvantage to the fetus from
this cause ; but the knots can be drawn so tight as to completely
shut off the placental blood-supply, especially in the case of
twins in a single amniotic cavity, where one cord may be drawn
in a tight knot about the other, obliterating the latter's blood-
. vessels. The gelatin of the cord is often displaced at the seat of
the knot, so that when the latter is untied its situation is marked
by deep depressions. " False knots" of the cord are localized
collections of the mucous tissue in it. A loop of the cord may
adhere by its proximal edges, giving rise to a lateral projection
such as is shown in figure 102, in which there is a loop of the
three blood-vessels.

Coiling of tlie Cord Around the Fetus. — Loops of the cord
may be wound about different portion.s of the fetal body. The

neck may be encircled once or twice, more rarely from four to
nine times (Braun), or loops may be thrown around the limbs.
The encircled part may be so compressed that it is strangulated
and the distal portion is destroyed, but it is doubtful whether a
constricting cord can ever determine the amputation of a part ;
for when it sinks through the soft tissues to the bones it there
experiences a pressure greater tlian it itself can exert, and is.
tlierefore, in its turn, destroyed (Braun). Thus the neck has been
severed to the spinal column, and limbs have been cut through
to the bone, but there the process u.sually stops,

Marginai and Velamentous insertion of the Cord. — The
cord is usually inserted somewhere near the center of the pla-
oenta. Aa the insertion approaches tlic edge of that organ, the

TJIK UMBILICAL CORD.

137

condition receives the name of marginal insertion, or battledore
placenta. If the cord should first enter the membranes at some
little distance from the placenta, to and from which the vessels,
unprotected and more or less separated from one anotlicr, pursue
their course between the amnion and chorion, a condition known
as insertio velamentosa exists. The explanation of such an oc-
currence is obvious : The allantois is conveyed at first indiffer-
ently to any portion of the periphery of the ovum, but as the
placenta begins to be differentiated the embr\-o, by a movement
of rotation, enables the umbilical vessels to pursue a straight
course toward their insertion in the placenta. Should the rota-
tion of the fetus be in any way interfered with, or should the
newlv-formed umbilical cord contract adhesions witli the amnion

l5(Wiockei

or chorion that would prevent the vessels following or comply-
ing with the rotation of the embrj-o. they would naturally enter
the membranes opposite the abdominal face of the embryo, or at
that point where adhesions arrested their movements. The blood-
vessels thus exposed are liable to laceration during labor, usu-
ally with a fatal result to the fetus unless delivery is quickly
effected .

Umbilical Hernia. — Occasionally children are bom with a
greater or less portion of the abdominal contents protruding into
the umbilical cord and covered by nothing but the distended and
attenuated amnion. There has been an arrest of development in

r:.^

?3=.ii

/-Vi.-i:

cti; ihciiminai ■:v:iiiS, preventing the irompietiijii t-^i tfie ar^
•Mt-: t.r:o=si by which die abdi^aniiiu i:a:vtcv- ia cioaeti.

Cysts •* tfce Cm4. — Cyscc liirmations in the coni :iri
c;rhcr 1: m -ibritrn-ii-v tTimi 'londicoc of tile mucL>iis cssi
^i.ir: r .1 :L:-uein:i:n ■:("iv:run in the petScJe ot the ;iIIanEois, tr.
:- h'-r5es. s-.vir.e, a-".L: ciiws is tbund persisting as a ^.-esid:*: a:

CafctT— 1 niniirtiiM — This comiict.iD .>f the con

.■■i.raai'Tj^!/ v.i^r.ii m-i is usually assi.iciatEd wttfa -synhiM^
'irr.e :rjy bi^ :ie^':siEiil in the waiii ot' bio«>i-viis;it;is or in

Tumors of the Cord. — Tumors of the cord may be c\-sts.

Incalizt'i hypertr'-jphit.-. '■■r accumulations of the mucous tissue.

nata. ;

hcmat'

lo; ). and tL-lanj;icctatic my
be excised immediately

ring. '

IV. Wirckcl. -McmralU. f. Gvi
lecled four o(her!>.

I'ttus amorphus, as in Budin's i

■ (Fig-

sarcomata. The last named should
birth, with, perhaps, the umbilical

1S94. p. 397. reponed one

cue and cot-

THE DF.CIDUM.

THEDEODUAE.
The explanation which John Hunter gave of the plates pub-
lished by his brother WilHam ' was, for a long time, accepted as
the true history of the development of the uterine membrane which
envelops the fetus at term. According to the Hunterian theory,
the uterus throws out upon its inner surface an inflammatory
exudate forming a closed sac whose walls stretched across the
openings of the tubes and the os internum cervicis. As the im-
pregnated ovule enters the uterus from one of the tubes it
pushes the sac-wall in front of it, but leaves behind it a bare surface,

,^«<

Fig. lo6. — Ulirus, decidua, and owum, on ihe eighth day of pregnancy (I^eopold).

which is soon, however, covered by an exudate similar to the
one at first thrown out. That portion of the original membrane
which remained attached to the uterine wall Hunter called the
membrana decidua vera ; that portion pushed out in front of the
ovule, the membrana rcficxa ; and that membrane last formed be-
hind the ovule, the membrana serotina. These names have sur-
vived until the present day, although modern investigation has
robbed them of their original significance. Costi ^ was the first
to expose the fallacy of the Hunterian doctrine, and since his time
the investigations of Robin, Friedlander, Kundrat, I^opold, En-

' " Anatomia ut. hum. grav. lali. illuslr." liirm., 1774, lable 34.

'"Origine de la Caduque," "Acad, del Sciences," Pam, 4 el 25 Juillei, 1841.

I40

PREGNANCY.

gelmanii. and others have enabled us to follow the changes that
occur in the uterine mucous membrane from the entrance of the
imprejjnaled ovule into the uterine cavity until the fetus, with its
envelopintj membranes, is expelled at term. By the time the fer-
tilized ovum arrives within the uterine cavity the lining mucous
membrane of the uterus has become very much thickened, ^ owinT
to a great increase in the interglandular connective tissue, which
consists of enormously enlarged young connective -tissue cells,
either closely pressed together or separated from one another by
the cellular amorphous substance characteristic of newly forming
connective tissue. As a consequence of tliis thickening the
mucous membrane is thrown into folds, and it is in a depression
between two of these folds of membrane that the ovule falls and
lodges when it first enters the uter-
<'■ iriL* cavity. The ovule, being thus

imbedded in the uterine mucosa, is
gradually inclosed by the arching
over of the folds of the membrane,
or, as Leopold " claims, by their
simple approximation owing to the
increasing thickness of the mucous
membrane. That portion of the
uterine mucous membrane upon
which the ovule rests, formerly
called membrana decidua serotina,
might be more properly termed, as
it is by the French, the placental
decidua, for it is upon this spot that
the placenta will be developed ; that
portion of the membrane which
arches over the ovule, called by
Hunter the decidua reflexa, is better named the ovular or epi-
chorial decidua ; and that portion of the mucous membrane that
remains as at first, atuiched to the uterine wall, the decidua vera
of Hunter, is more appropriately spoken of as the uterine decidua.
The changes that occur in this last division of the uterine mucous
membrane as pregnancy advances are, up to a certain point, only a
continuation of the change al ready noted. The large cells already
referred to, the decidual cells of Friedlander, multiply with great
rapidity and constitute a thick layer, — the upper portion, or com-
pact layer, of the uterine decidua. The glands which at first send
their ducts up through the cellular layer of decidua are at last

n t-Stlinw

' Tenfold. nccordinE lo Engelmann
' •' Archiv f. Gyn.,'" lid. w, S. 455.

n- Jour. Ohsl

" May, 1875).

Fig. IQv.— The dccidua vcta and lliu

^..

THE DECIDUM.

143

confined entirely to the deeper portions of the membrane, consti-
tuting, finally, what is known as the glandular or spongy layer.
In its L-arly stage of development the uterine decidua is richly
supplied with blood ; the capillary loops spring up luxuriously
into the interglandular spaces ; while deeper down, between the
glandular layer and the uterine muscle, may be found numerous
and extensive blood -sin uses. As, however, the ovular decidua
comes in contact with the uterine decidua, tlie blood-vessels arc
subjected to pressure and the Stage of atrophy begins in the endo-
metrium. The blood-ve.ssels disappear ; a fatty degeneration may
be seen in the cellular layer ; no trace of epithelium remains in tlie
superficial layer of the membrane, although epithelial cells persist
in the glandular layer; and, finally, as labor begins, the uterine
decidua separates into two parts, the line of division running

through the glandular layer, or between the compact and glan-
dular layers, the latter remaining behind in the uterus to furnish
the nucleus of a new mucous membrane, which .soon after labor
takes the place of that which has been partly cast off The history
of the ovular decidua is one of atrophy almost from the beginning.
As the growing ovum pushes out this portion of the uterine
mucous membrane upon the pole of the sphere directly opposite
the placental decidua. the epithelium of the membrane begins to
disappear and the blood-vessels are soon obliterated, so that at the
end of the third month, when the ovular comes in contact with
the uterine decidua. the former consists of not much more than a
single layer of flattened and elongated cells. The development of
the placental decidua has been described with that of the placenta.

•.-2.'- -. .tJ. '. - .

'•i . . ' .^'

.■>» »«v

*M OIK LJK^i^HBL — riie ieoduai mucous membrane

r-^--;!.:: .Kr::^ nnv ^ :iie -rtiar •:' nnry ■ >r" the iistasis

:.. "Ze ncomL- rrrim 'i *!:u :i»jn-';^7nvrJ. uceriLi. In liid

zz^. .• *<-'.vr. iacosiea .on'.:itaj:ii5 'luiii Tiaime<t ditm-

:::i^^. = nt::-- :rm:3, '-.vin^- :i. "jit • iiormun:^ UTJcrtr'.Diiv

: :„j- •nc-incmiini ■■an .ia.\e more: >*;rn.»us ■_*•_> n^retiucncss

-'- , - ~"

■> >.-^:

Tlr-Il. r-in,. :

• » •

■

> >

ti-.'-.v.i.-.

•

-7

Hf-.n-if. r

•

• -

•■:..:.: i -r

^, .. .. .,..

•-

. ■ 1 "

- 1

I.- i" —

.■"*.'«. ■* -T •'". '

.■t;-:iMi.

I."

.i • -■

-.r 2 i-'-'M.

;ir

;iv -r

r -»»;i'..ir.i:c'r

"- fl
;: .:"r

niKc .nj.cj, 'Dut in Its .steaii ±c

nucjiii membnuie may ^.> -^n tJ

u! ncrea<e n diut In-peraiasii

v..;j:i < I cviiijtiuit piitmomencfi

ill tne viurii^-r 'jtiiirti*^ .jj" i^jj ,^|-.

.'Oiooment. Hie cause *:i rns

?\-cmcvt:ii ipmeni: will usually

^e ound :n a prtiexistinc ci^»i«>

mtirnns. '.vhicii piTf»iisT>.-ses tie

membrane O) nssponii \vit:i inor-

■ iinate viinjr to nhe sdmiiljs

viiich in imprti-^ated owk

ii'v.-iys filiTrisaes die uterine mu-

j sa x^ rapid ^^Jwth and de\^-

-irraent: Et may be p«:>sabfe.

::. H-er-r. diat die death of the

:!rr.i:r> >; :r s«jme disease of die

- -mi may p^^v^ irritatiiig

±rj inrh t? incite rfie mucous

nembnine «-'»f the uterus, pre^i-

::i>r healthy, to o^-ergrowdt

:L:e n:^::'-:s membrane are more or

.e.^^i =s-y:.V

.:. '••- \.!. :>.r: rr-iT.irescir:' ■ T-s '.-^r" die disease \^ar\-.

iMHine Hyperpfaun otf the Decidial rBliiwHifci ^Thxs concfi-

t.V>r. ^.r* thr: m io-zj.-^ mr^rrZ-jr^r-.e Cjr^i^ts of a progressioii of the
hyz^'.Tzy.^M^ that occurs n- .rm.i::y in the early months of j
\yit 'A-hich in these ca.v:.s i.s. from the be^^inning, e^
The <^t(:Hf\y increa^v: in ail the elements of thedecidua with"
(ff le.^ri rapirlity rer»ulLs in the prr>duction of a membrane of van-ine
thicknefis and density, but always far in excess of the size of the
normal decidua: at term. Should the disease ad\*ance wth eicat
rapidity, an afK>rtion will usually result, either on account of the
hemorrhages into the mucous membrane, separating it from the

THE DECIDUyE, 1 45

Uterine wall, or owing to the death of the embryo, from which all
nutrition has been diverted to supply the greater needs of the
rapidly growing decidua. In such cases the embryo may be
absorbed and the deciduae afterward cast off as an empty sac
with greatly thickened walls, forming one variety of the so-called
fleshy moles. ^ Or, the embryo may be destroyed in conse-
quence of the hemorrhages into the hypertrophied decidua, the
blood bursting its way through all the membranes and occupying
the cavity of the ovum, as well as surrounding it exteriorly, so
that only with a microscope can one detect the true nature of the
mass expelled. 2

On the other hand, if the development of the decidua goes
on slowly and evenly, the fetus may not be expelled before it
becomes viable, or even until the normal end of pregnancy. *
The structure of the hypertrophied decidua is usually only an
exaggeration of what may be seen in the decidua of early preg-
nancy. There is a great multiplication of the decidual cells,
some of which are elongated and seem to be transforming them-
selves into connective tissue ; the blood-sinuses are much en-
larged in the deeper portions of the membrane, and there is
usually an abundance of connective tissue. Madam Kasche-
warowa* has described new-formed muscular fibers in a hyper-
trophied decidua, and occasionally either the cellular or the
fibrous element has been found greatly to predominate.

The cause of hyperplastic decidual endometritis has been
already referred to. The determining cause of the hemorrhages,
or ** apoplexies of the ovum," so often destructive of the embryo
and provocative of abortion in this affection, may be anything
that would produce congestion of the pelvic viscera, such as
physical exertion, plethora, coitus, or the recurrence of the time
for a menstrual period.

The effect of hyperplastic endometritis is usually disastrous to
the embryo and injurious to the mother. The hemorrhages into
the decidua may grow excessive in amount, but more frequently
the maternal health is endangered by the retention of portions ^of
decidua, owing to adhesions between the diseased membrane and
the uterine wall,^ after the remainder of the ovum is cast off. Espe-

* Schroeder, ** I^hrbuch."

* Priestley, he. cit.^ p. 28, who quotes Clendrin, Ilegar, and Westmacott.

' I have seen a living fetus, delivered at tlie sixtli month, from a woman who
three days afterward expelled a piece of decidua I cm. thick and measuring 6 cm.
in diameter.

* Virchow's"Archiv,'* 1868, Bd. xliv, p 103.

* This is particularly true of syphilitic endometritis. See Kaltenbach, '* Zeits.
f. Gebartsh.," Bd. ii, p. 225.

146 PREGNANCY.

dally is the placental decidua apt to surpass in its hyperplastic
growth the remainder of the decidual membrane and to be retained
in utero. to give rise to hemorrhages or, by its decomposition, to
septicemia. This is the condition often described as placental
polyp and as polypoid hematomata of the uterus.

Polypoid Endometritis. — Instead of being evenly and generally
thickened, the decidua may display at certain points a less pro-
nounced hypertrophy, or. on the other hand, upon the uterine
surface maybe seen projections or excrescences where the hyper-
plastic process seems to have been exaggerated over a limited
area. Such cases have been described by Hofe ^ and Schroeder.^
It is, however, to the most advanced tj'pe of this polypoid condi-
tion of the uterine mucous membrane that Virchow ^ first gave
the name of endometritis decidua polyposa or tuberosa.

In these cases the internal surface of the decidua presents a

most peculiar appearance. Villus-like projections stand out from

the degenerated mucous membrane to the height of half an inch

loth of surface and v<!ry vascular. In the intervals

between the projections may be seen the openings of the uterine

glands, ivlii.-li 3Tf ti.it f(. K- t.iiin.l fit! Hu" polypoid elevations.

, The wli 'I, which, as a micro-

tscopic I • i .it hypertrophy of the

Econncctj i':n:ase in the decidual

THE DECIDUM.

147

cells, which contain nuclei of enormous size. The connective
tissue forms fibrous bands constricting the openings of tlie uterine
glands, as well as the blood-vessels in the diseased membrane ;
and yet the whole decidua is exceedingly vascular. In Virchow's
case there was a syphilitic history, and, therefore, he ascribes
the disease to syphilis ; in other instances no cause whatever
could be discovered, but often tliis disease, as well as other
affections of the decidual endometrium, depends upon a pre-
existing chronic endometritis. It is a disease of young ova, and
frequently the chorion villi implanted in the diseased mucous

membrane are in a condition of myxomatous degeneration.' In
all the cases hitherto described the ovum has been expelled at
the end of the second to the fourth month of pregnancy (Schroe-
der). Polypoid endometritis is closely simulated by blood
extravasations between the decidua and the chorion, as shown in
figure 115.^

Catarrhal Endometritis. — A chronic inflammation of the de-
■ndometrium will occasionally affect chiefly the glandular

1867.
f. Gyn.." 1892, p. 707.

PREGNANCY.

elements of the membrane, with the result of a hypersecretion
of a thin, watery mucus, which, collecting between die chorion
and decidual, may be suddenly expelled, after a rupture of the
ovular decidua, in the later months of pregnancy. This oc-
currence gives rise to sudden gushes of fluid from the vagina,
which may reach a pint in quantity. Afterward the fluid may
dribble away for a considerable length of time without affecting
seriously the course of pregnancy, or else, collecting again in
considerable quantities, it may excite the uterus to muscular

Fie ■■

(author

action. This aflection occurs more frequently in multipara: than
in primipar.t. and scfins to df|jeiid in some cases upon a watery

I CondilK'i' ' The mucous discharge is one

I of tht 1 iil.irum.

Ct-t . ■ I ■■ L^fif-.iild Vit A hyV^^fsecretion of

'ottVained in tlie
.,,,(1 results, only
,^,\owettitiB. It is
.^ qiate (

THE DECIDUjE. 149

stantly in the earlier stages of the chronic hyperplastic decidual
endometritis already described, the glands being destroyed and
obliterated as the disease advances. A section of mucous mem-
brane affected with cystic disease presents a somewhat cavernous
appearance, numerous small cysts being scattered throughout
its thickness. Their connection with the uterine glands can be
demonstrated by the relation between the cysts and the ducts of
the glands. ^ About the cysts the decidua is hypertrophied, pre-
senting the overdevelopment of connective tissue, increase of
decidual cells, and embryonal tissue that has already been re-
ferred to. 2

As to the prognosis of all these chronic affections of the
decidual endometrium, it is, as may be inferred, decidedly un-
favorable for the fetus and by no means entirely favorable for the
mother. The danger to the fetus from hemorrhages, which
bring about separation of the membranes, or which, bursting
through all the fetal envelopes, overwhelm the embryo with
blood, has been mentioned, as well as the diversion of nutriment
from the embryo to the overgrown decidua, and the excitation
of muscular action upon the part of the uterus, which ends in the
expulsion of the ovum. But the possible loss of blood during
pregnancy, and the retention of fragments of decidua owing to
adhesive inflammation after the ovum is expelled, can not be
regarded with indifference as to their effect upon the mother.

The treatment of this condition during pregnancy is impos-
sible. Its prevention may be attempted, however, by a curet-
ment before impregnation occurs again.

Acute Inflammation of the Decidual. — Acute inflammation of
the decidual membrane may develop in the course of cholera
and other infectious diseases, esf)ecial]y the exanthemata, or in
consequence of unsuccessful attempts to bring on abortion, or
perhaps as a result of external injuries.

Hemorrhasic Decidual Endometritis. — This is the name given
to the condition of the mucous membrane found in two cases of
cholera,^ and, no doubt, present in other grave infectious diseases.
In these instances the decidua was thickened, of a dark, purplish
hue, and presented throughout its substance numerous extravasa-
tions of blood.

Exanthematous Decidual Endometritis. — Klotz. ^ in a study of
the effect of measles upon pregnancy, in eleven cases noted in

* Leopold, **Gesellsch. f. Geburtsh.," Leipsic, Feb , 1878.

'See Breus, •* Ueber cystose Degeneration der Decidua Vera," '*Archiv f.
Gyn.," Bd. xix, S. 483.

•Slavjansky, " Archiv f. Gyn.," Bd. iv, S. 285.
♦"Archiv f. Gyn.,'» Bd. xxix, S. 448.

1 50 PREGNANCY,

nine a premature expulsion of the fetus, the time at which the
expulsive efforts began seeming to bear a relation to the outbreaks
of the eruption upon the skin. In these cases, according to Klotz,
the uterine action is excited by the occurrence of an exanthema
upon the uterine mucous membrane, highly irritating in its action,
just as the photophobia, thecoryza. the bronchitis, and the vesical
tenesmus of measles indicate an irritated condition of the mucous
membranes of the eyes, nose, lungs, and bladder. It is quite
probable that the same condition of the uterine mucous membrane
mi^ht account for the abortions or premature labors that often
occur when pregnant women are attacked by any of the eruptive
fevers.

Purulent and Microbk Decidual Endometritis. — Donat ^ has de-

scrilxHl a c*iso of purulent endometritis in pregnancy. A woman
exjx.'llcd at term a placcnti about the periphery of which could

be seen masses of decidua infil-
trated with pus. The amnion and
chorion were both thickened and
opaque, and between them was an
accumulation of purulent fluid
It was suspected that the suppur-
ation of the decidua was the re-
sult of unsuccessful attempts on
the part of the w^oman to bring
on a miscarriage.

Atropliy of tlie Deciduie. — The
Fiji. 117.— Atrophy ottlu drcidiia, ex- dcciduae, instead of undergoing
trnud Mitiacc ot iiu- vor.i vDiuicaM -. inflammatory and hyperplastic

changes, may, on the contrar>%
atroph)'. altliouL;li such an occurrence is doubtless rare. This
chan*^c in the liccidual membranes has been described by Heear ^
and Mattliews Duncan,^ and, among more recent writers, by
Spicgcll)cr«^ ** and Priestley.^ The uterine, ovular, or placental
dcciduiLMnay singly or conjointly be the seat of atrophy, resulting
either in the ovum being attached by a mere pedicle of slender
proportions to tiie uterine wall, or else, in the case of atrophy of
the ovular decidua, the cmbr\'o lacks the outermost of its protec-
tive membranes, and, consequently, the ovum may rupture and its
contents be discharged from the uterus. As a result of the
stretching of the pedicle in cases of placental atrophy, the ovum

* " Archiv f, Gvn.," Bd. xxiv.

* ** Monatsh. f. Geburtsh. u. Fr.," Bd. xxi ; Supplem., pp. II, 19, 1863.

* ** Researches in Obstetrics," p. 295, 1868.
***Lehrbuch," p. 328. » Op. cit.

THE DISEASES OF THE FETUS, 151

may be pushed downward by the uterine contractions until it
rests in great part within the cervical canal. This condition con-
stitutes the cervical pregnancy of Rokitansky.

CHAPTER V.

The Diseases of the Fetus.

Fetal mortality exceeds that of any other period of life. It
has been estimated that for every four or five labors there has
occurred one abortion, and if to this number be added the still-
births in which the death of the fetus was not due to an accident
in labor, the proportion of fetal deaths to living births becomes
very large. In addition to the diseases having a fatal termination,
there are others affecting the fetus in utcro running their
course wholly or in part during intra-utcrine life and ending in
recovery ; so that the list of fetal diseases is an extensive one.

The present chapter treats of the diseases of the fetal or-
ganism itself, of weakness dependent upon defects in the
paternal elements entering into the composition of the embryo,
and of maternal conditions which are incompatible with the
healthy development or with the continued existence of the
product of conception.

Fetal Syphilis. — First in importance of all the diseases of
intra-uterine life, fetal syphilis deserves a somewhat extended
notice. According to Ruge,^ eight>'-three per cent, of repeated
premature and still-births have their cause in syphilis of one or
both of the parents. Of 657 pregnancies in syphilitic women col-
lected by Charpentier, 2 thirty -five per cent, ended in abortion,
and of the children that went to term a large number were still-
bom. Of 100 conceptions in syphilitic ^ women, only seven
children were alive a year later.

The Syphilitic Infection of the Fetus. — If the woman be syph-
ilitic, the ovule is diseased before its impregnation ; or the sper-
matic particle from a syphilitic man carries the infection to the
ovary of a healthy woman. Modern investigation shows, more-
over, the possibility of infecting the healthy fetus at any time
during intra-uterine life should the mother acquire syphilis during
pregnancy.

* Sec Lomer, ** Zcitschr. f. Geburtsh.," IW. x, p. 189.

* •• Traits prati({ue des Accouchements."

» Pileur, ** Bull, de laSoc. d'Obst. et de Gyn.," Paris, Dec. 13, 1888.

152 PREGNANCY.

Syphilis may be transmitted from a syphilitic father direct to
the embryo without the previous infection of the mother. As
the fetus grows, however, and the syphilitic poison develops with
its growth, the mother becomes infected in her turn directly from
the fetus through the uteroplacental circulation.' The longer the
time since the acquisition of the disease by either parent, the less
likelihood will there be of the production of syphilis in the
embryo ; but the limit of safety has not yet been discovered.
According to Fournier,* four years is the maximum of time that
syphilis can remain latent, but Lomer ^ tells of the production
of a syphilitic infant ten years after the first infection of the father,
and Kassowitz^ records a latent syphilis of twelve years' dura-
tion.

Lusk said that "the syphilitic poison will not traverse the
septa intervening between the fetal and the maternal vascular
systems " ; but Vajda * and Hutchinson ■ describe cases in which
pregnant women were infected near term and gave birth to syph-
ilitic children. Neumann ^ also has published observations
of 20 women who were infected with syphilis during pregnancy ;
5 of this number gave birth to syphilitic children, and of these 5
2 were infecte'd at the fourth and i each at the third, seventh.
and eighth months, llirigoyen * has reported \2 ca.ses in which
the mother contracted syphilis during the first four months of
pregnancy ; all the children were still-bom ; in cases of infection
from the fourth to the sixth month, about half the children were
still-born ; and in 7 cases of infection during the last three months
of pregnancy there were 4 still-births, ^

jVUinlfestallons of Fetal Syphilis. — Syphilis acquired by the
embryo at the moment of conception from preexisting sj-philis
of the ovule, or of the .spermatic particle, or of both, or trans-
mitted to the fetus from the motheratany time during pregnancy,
manifests threat variety in the tissues attacked and the lesions
produced. Thus tliere are bullous eruptions of the skin, condy-
lomati, and inflammations of the mucous membranes, inflamma-
tions of the serous membranes, gummatous and miliary deposits,

I See Taniier el Budin, of. at. ; Prieittej, loc. dl. : J. Hutcbinson, " British
Meil. Jour.,' Feb.. i8«6, p. 339; Hwrey, " Fetuf in Ulero," 1886; G. S. West,
"Am. Jour. Obstethci," 1885, p. iSa.

*"2oll«lit. f. GfUrlsli.," IM. I, 94-

Head of femur removed from a felus expelled, (lead nnil macerated, i
«ev«iilh month. 'I'lie liver weighed one Ii-nth of the IxKly-weiglit; ihe ipleeii
forty- eighth. The imillier was inrvcted with sypliili* one year before (aalbor'ii
IliiiadGl^ia llotpital).

THE DISEASES OF THE FETUS. 1 53

and morbid growth of connective tissue in the brain, lungs, pan-
creas, kidneys, liver, and spleen, the muscular system, and the
coats of the intestines and walls of the blood-vessels, and a char-
acteristic osteitis and osteochondritis.

Prognosis. — The influence of syphilis upon intra-uterine life is
most unfavorable. If the fetus is not destroyed before it has be-
come viable, it is often born with signs of retarded development,
performing in an imperfect manner its vital functions, or else ex-
hibiting well-marked signs of disease in an enlarged abdomen, due
to ascites, to enlarged liver or spleen ; nodes in the lungs or
in the bronchial glands ; hydrocephalus ; separation of the epiphy-
ses of the long bones from the diaphyscs ; extensive pemphigoid
eruptions on the skin, or, perhaps, presenting a deformed or
monstrous appearance. There are cases, however, in which the
course of intra-uterine life does not seem to be influenced in the
slightest degree by syphilis. The children are born apparently
healthy and well developed, but exhibit unmistakable signs of
their hereditary taint within the first few weeks after birth.

Diagnosis of Fetal Syphilis. — The infection of the fetus may be
inferred with reasonable certainty if either parent had acquired
syphilis at a date not too remote from the procreation. If a
woman should acquire a chancre during pregnancy, the possi-
bility of the disease attacking the fetus must not be overlooked.
A trustworthy sign of syphilis in the fetus is occasionally found
in those cases in which the ovum is infected by the spermatic
particle. The woman may remain perfectly healthy until toward
the middle of pregnancy, when signs of secondary syphilis may
appear, without the slightest trace anywhere of a primary sore.
In such cases the poison of the disease has been transmitted from
fetus to mother.

Very often the signs of fetal syphilis can be looked for only
in the fetus itself, after its expulsion from the uterus, and much
may depend upon a correct diagnosis. This is, however, not
always easy to reach. The parents* histor>% from ignorance or
design, may be entirely negative. The child may be born with
no distinctive sign upon its body. If it is living, however, the
coryza and characteristic eruptions during the first few weeks
usually point clearly to the hereditary taint. If the child is dead,
the diagnosis can easily be made.

If the practitioner is a trained pathologist, the detection of
syphilis should give little trouble. The bullous eruption on the
skin, the condylomata and inflammations of the mucous mem-
branes, the inflammations of the serous membranes, the gumma-
tous deposits and the morbid growth of connective tissue in the
brain, lungs, pancreas, kidney, liver, and spleen, and in the coats

1 54 PREGNANCY,

of the intestines and walls of the blood-vessels, along with a
characteristic osteochondritis, should demonstrate the character
of the disease. It often falls to the lot of the ^jeneral practitioner,
however, to obser\'e cases of repeated fetal death the cause of
which is obscure, although suspicion naturally rests upon s\T)h-
ilis. Thanks to the investigations of Wegner, ^ Ruge,^ Lomer,^
and others, it is now well established that syphilis can be reccx^-
nized in the fetus by a few signs easily found, perfectiy reliable,
and requirin^^ for their detection no special training in the
methods of patiiological research. Wegner was the first to call
attention to a curious condition of the dividing line between dia-
physis and epiphysis of the long bones of a syphilitic infant
Instead of a sharp, regular, delicate line, formed by the immedi-
ate apposition of cartilaginous to bony tissue, as in a healthv
fetus, there may be seen in syphilitic cases a jagged broad line,
of a \'cllow color, separating bone from cartilage'* (Plate 3).
A microscopic study of this portion of the bone shows that there
has been a premature attempt at ossification, which has ended in
necrosis, fattx' degeneration, and suppuration.

l^'or more than a year I carefully looked for this sign in ever}*
case o\ unmistakable fetal syphilis that occurred in the Philadel-
phia and Maternity Hospitals, and never failed to find it, while
in douhlhil cases it proved a valuable aid to a correct dia^osis.
In the r'raucnkiinik. at Berlin,^ this sign was also carefully inves-
ti^^ated. with a result wholly favorable to its distinctive character.*

AccordinL:^ to Ruge,^ the liver of a healthy infant should
constitute about -^^ part of the body-weight. In swhilitic
infants, however, this proportion is much exceeded, the liver
forming, in extreme cases, \ of the total body-weight The
spleen, too, is much enlarged in syphiHs. This organ which
in a normal fetus at term should be in weight -J-^. part of
the whole hcxly, often much exceeds its due proportion. Upon
these three si^ns, — the yellow line between epiphysis and
diaph}'sis, the increased weight of liver, and increased weight

1 Viichow's ♦' Archiv." Hd. i, S. 305.

2 " Zcit. f. C.clnirtsh.." Bd. i. » //„>/., i^d. x.

* To discovtT Werner's sip^n, an incision should be made over the trochanter «s
thouj»h for excision of the liead of tlio femur. The end of the thigh-bone is turned
out after cutting; its lii:[aments, and a median section of the epiphysis and diaphvsis
of the l)one is made with a strong cartilage-knife.

* Lomer, loc. cit.

* Zweifel thus describes the progress of the disease : ** There is formed in a cer-
tain region of the cartilage, granulation-tissue insufficiently .supplied with blood-
vessels and ill -nourished. There results necrosis of this tissue, with an attempt ^
exfoliation and accompanying suppuration."

"' Loc. cit.

Syphilid of ihe fclu*.

THE DISEASES OF THE FETUS. I 55

of spleen, — all easily discovered, the diagnosis of syphilis may
rest with reasonable certainty. If one would push the investiga-
tion further, perhaps the next surest indication of syphilis might
be found in the lungs. ^

These organs manifest a syphilitic infection in three ways :
By an interstitial overgrowth ; by the presence of gummata ; by
a peculiar catarrhal inflammation, resulting in what is called white
pneumonia. The interstitial overgrowth is the most common.
The connective-tissue overgrowth about the blood-vessels and the
alveoli gives the lungs greater weight and more solidity than they
should possess ; their color is often dark red ; if the infant has
breathed, as it commonly does — although imperfectly — ^for a short
time after birth, the lungs will not float buoyantly, although they
do not usually sink outright. Microscopically, it may be seen that
the alveoli are much encroached upon by the interstitial thick-
ening, and that lung-expansion and adequate respiration are im-
possible. The catarrhal pneumonia /';/ utcro due to syphilis is
rare. The lungs in this form of the disease arc large and heavy ;
they quite fill out the thoracic cavity and bear upon their external
surface the imprint of the ribs ; in color they are yellowish white,
the whole organ having undergone a more or less complete fatty
degeneration. This condition is incompatible with extra-uterine
life : the infant never breathes.

Treatment. — ^The treatment of fetal syphilis during pregnancy
consists of a thorough course of antisyphilitic treatment in the
mother. Should it be clear that the fetus derives its syphilis
from one parent alone, while the other remains healthy, then, of
course, treatment of the healthy individual before impregnation
occurs would be superfluous ; but in case of doubt it would be
wise, in the preventive treatment of fetal syphilis, to administer
to both man and woman the appropriate remedies.

Should a pregnant woman come under the observation of a
physician with the history that she had had syphilis, that she was
with child by a syphilitic man, although healthy herself, or that
she had acquired a chancre subsequent to conception, she should
receive mercury and iodid of potassium. I prefer mercurial oint-
ment inunctions daily, and about 15 gr. (0.972 gm.) of iodid of
potassium three times a day, after meals, in milk, during the whole
duration of pregnancy. Under this treatment I have seen women
who had given birth to a succession of still-born syphilitic fetuses
bear living children perfect in health and development, without a
trace in after life of their hereditary taint.

* For an exceedingly interestinfj |)aper on this subject see Heller, ** Die Lunj^-
cnerkrankungen bei angeborener syphilis," *■ Deutsch. Archivf. klin. Med.," Bd. xlii,
S. 159.

1^6

pj^EGx^.vcy:

OtiMr Inieaiotis Diseases of the Fetus. — As the infectious

vL5cM5o> arc dependent upon the entrance of bacteria into the
<> >tcm for their characteristic s>Tiiptoms, it is impossible that they
shvvuld directly anect the fetus in uUro, unless pathogenic micro-
orv;^in*-sais are able to pass from the maternal blood through the
uterv>placental septum into the fetal fK>rtion of the placenta.

Brauell ^ and Davaine.^ experimenting with the bacillus of
anthrax, sau lar^ colonies of micro-organisms heaped up on the
maternal side of the uteroplacental septum, but failed absolutely
to find a trace of them in the placenta or fetus. Straus and
Chamberiand * railed to infect animals by injecting the blood of
a :ltu5 taken from an animal that had died of anthrax. Run<^
of IV^rpat, :n».xuiated a number of rabbits with tuberculosis but
\\a> never able to detect a characteristic bacillus in the fetus.
Chanihrvlcni * quotes Hudin, Tamier, Charpentier. Hoffman,
la>>:r.sk\ . and Fehling as denWng the possibilitv- of the passa^
of ni:crobc5 from mother to fetus. \'. Ott ^ expresses his dis-
b^licf m the T\\s>.i^e of solid particles into the placenta, and
>iip:v >rt> his staiemeni by describing experiments of his o\ni
wir.v.':: altered the constitution of the maternal blood without
affc^:;:\i; liwt of the fetus. Wolff** infected a number of pr^-
narn rahhits and guinea-pigs with anthrax, and failed entirely
to :".:\: a trace oi' the disease in their young. Curt Jani," an
aNsstar: v f Prof W'eigert. of Leipsic, having an opportunity- to

hixl\* of a woman who had died in the fifth month

exan-i.r.v tin _

of pT\ i;'^^''.•^'^ from i^eneral miliar)' tuberculosis, found not a trace
of tb.v^ !uv;'..: o-' tulxTculosis in the placenta or fetus althou<^h
ovoTA r.iateir.al or^an was markedly affected. Urvitch ® inocu-
latvvi s<\e:'. -ore-^nant mice with the microbes of mouse-septicc-
nv.a, av.vi 'v^iitvi the sjxxific microorganisms in great quantities
t)iro;;j;>. tlv maternal tissues, but they were entirely absent in
tlv -olavOT^ta and fetus. Inoculations with the blood of the
n^ot]^ r Nr.v.mals were invariably fatal to other mice, while the
total MvVtvi was entialy inert. Finally Bompiani ^ delivered a
wonun who was sufferinc: from anthrax, but whose fetus shou^i
no s:ii;n x>f iho djs^Mst\

• \mVx* V '^ Vn^^x." viv 1S5S. p. 4>0.

- r,yv.]'«rov ivtN^n* 00 U S.xwJt«^ ile Biologie," 1882, p. 689.

'^ Ktvhmlv- ^r.) lo rAv>;A|rf *<<^ fel^rocnts figures k iravers le Placenta," Pairs.

iSJ^.V

" AnwA^ .^ ^Mv1A Ma^^ .<w"^> ^^"^'^

//>i(/.^ ciii, p. 522.

THE DISEASES OF THE FETUS. I 57

But, on the other hand, not only microbes, but even small
particles of colored substances, like ultramarine blue and cinna-
bar, have been found in the placental and fetal structures after
they have been injected into the maternal tissues. In 1882,
Arloing, Cornevin, and Thomas ^ showed the possibility of the
passage of anthrax bacilli from mother to fetus ; and in the same
year Straus and Chamberland, although they at first supported
the views of Davaine and Brauell, finally changed their opinions
and announced their belief in the transmissibility of contagious
diseases to the fetus in utero.'^

Chambrelent ^ also was able to cultivate the microbes of
chicken-cholera from the fetal blood, and to reproduce the dis-
ease by inoculating an animal with the cultures. Mars,* of Cra-
cow, found, after injecting putrid solutions into pregnant rabbits,
not only in the maternal but also in the fetal blood, a great
number of bacilli ; and Dr. Pyle,^ working in the pathological
laboratory of the University of Pennsylvania, under the superin-
tendence of Dr. Formad, obtained practically the same results.
In a human fetus removed from its mother by Cesarean section
on account of her approaching death from septicemia, he
found vast numbers of micro-organisms in its blood. Koubas-
soff,^ after experimenting under the supei^vision of Pasteur
in his laboratory in Paris, claims never to have failed to find
the anthrax bacillus in the fetus when the mother had been
thoroughly infected with the disease, except in one instance,
where of two fetuses one was partially macerated and its pla-
centa the seat of hemorrhagic extravasations, while the other
was well developed. In the former no bacilli were found, but in
the latter they were present in large numbers. Upon this obser-
vation Koubassoff bases the conclusion that the placenta can
only offer effective opposition to the passage of microbes when
its condition is pathological. It appears from these conflicting
statements that micro-organisms may pass from mother to fetus,
but will not always do so. Moreover, the list of diseases which
depend for their existence upon the presence of specific micro-
organisms, and which have in certain well -authenticated cases
undoubtedly attacked the fetus /;/ t4tcro, is a long one ; so that
the possibility of fetal infection from the maternal blood can not
be denied.

* ** Comptes rendus des Stances de 1' Academic dcs Sciences," 1882, xcii, p. 739.

' Sec Koubassoff, ibid.y vol. c, p. 373.

■ ** Rccherches sur le Passage des fel^raents figures k travers la Placenta," Paris,
1883.

* Abstract by Chambrelent, *• Archives de Tocol.," 1883, p. 381.
» ** Medical News," Aug. 30, 1884. • Loc. cit.

I ^ ^

•— . • ~ ■^.-

.■.»i> .- ..

-^-.^V

"-^ m.'Uii:.

" i I ..iTC

^: " .::.. cri-: l\Vi.

/
/

'■"'■ ste:. Jour.

; I

THE DISEASES OF THE FETUS. 159

are also cases recorded of measles appearing in the first few days
of extra-uterine life, making it probable, from the short period
of incubation, that infection had occurred /;/ utero.

Scarlatina. — More than one eminent authority has expressed
a doubt as to the occurrence of scarlet fever /;/ utero ^ but the
evidence, although scanty, is conclusive that on rare occasions
children have been bom with a well-marked scarlatinous rash
upon them. Dr. Leale,^ of New York, described a case in his
own practice in which a boy was born at the beginning of a well-
marked attack of scarlet fever in the mother, which she had con-
tracted from an older child. The new-born infant presented a
dark, congested, red hue and a characteristic raspberry tongue.
The eruption lasted seven days and desquamation began on the
tenth day, at which time the albuminuria and general anasarca
pointed to a desquamative nephritis. This child recovered.
Dr. Leale was, moreover, able to collect a number of cases re-
corded by Hiiter, Meynet, Asmus, Baillou, Tourtual, Gregory,
and Stichel. Dr. Wilson Saffin,^ of Carthage, Ohio, has also
reported a very interesting case of scarlet fever in utero : A lady,
who had had scarlet fever in childhood, was nursing her child
through the disease, while she herself was in the last month of
pregnancy. She was apparently not infected, but complained
of a bad sore throat. Two weeks afterward she was delivered
of a male child with a typical scarlet rash upon it ; the disease
ran a course of nine days, with desquamation in large and small
flakes, beginning on the fifth day. The infant's temperature
ranged from 100° to 104° F., and the attack ended in recovery.^

Erysipelas. — Kaltenbach,^ in 1884, observed a child, born of
a woman who had had erysipelas in the last month of pregnancy,
that a few days after birth shed its skin as if it had had an attack
of erysipelas /;/ utero. Runge ^ and Stratz ^ have described
similar cases, but Tamicr ^ calls attention to the fact that des-
quamation in the healthy new-born infant is not an uncommon
occurrence. Lebedcff,® however, has presented convincing
evidence as to the possibility of intra-uterine erysipelas in the
following case : The child of a woman delivered at the seventh
month in the midst of an attack of erysipelas presented alternate

» "Medical News," 1S84, p. 636.
2 « New York Med. Record," April 24, 1886.

■ For full bibliography see Ballantvne and Milligan, **Edinb. Med. Jour.," July,
1893-

• *'Centralblatt f. Clyn.," No. 44, 1884.

» " Centralblatt f. Gyn.," No. 48, 1884.

• ** Centralblatt f. Gyn.," ix, 213. » Loc. cit.

• **Zcitschr. f. Gel)urt.," xii, 2, p. 321.

riii:hi> -y Tfz inc nhite on its sldn at birth ; it lived ten minutes :
iTicr i::jir. si'ti^torccci were found in the subcutaneous adipose
ti>>_". . a-.r.. r-itr.-aic-d. and rabbits inoculated unth the cultures
3.C .^:t:sz :>. iiscisc. No microbes, however, were found in the
i.ic-.r.ra -r c-yrd. Lebedcff belie\es that the specific microbes
er.tcrc-i thr placenta through a \-illus dq^rived of epithelium.

.Hatarim. — Amoiu: others, Burdd ^ expressed his disbelief in
xhz ;.xi>:'wr.:c ■*:" congenital malana, and Tamier quotes Leroux
a> Ni/.r.: rhii ■ as yd 31 is impossible to say positively that con-
^-cr.::^.' m^.^r-a -.xists ' ; * but ihe testimony as to the occurrence
o: >yr.\] t :::> :" c:>:iirbance in the unborn fetus at re^^ular inter-
\a.>. : rrL>> r.c:n^ or not to the attacks in the mother, and the
ir.<±:.:rl--l^t: r.s cr ^,x:r.>iica] seizures, bc^ning immediately after
b:rth. :- cuitt voluminous and of a credible character. Behr-
mann r^-it-.s ^ iao cases of intra-uterine infection in which the
(ii>c'a>c ::.-i:.::ls:L^: :t>cif directly alter birth. Dr. \V. T. Tavlor.
of Ph:!a.i-..p:.:.i. : 'resented to the Philadelphia Obstetrical Societ\'
tr.'j :::>: ry .•:" u lacy who. ha\-ing lived during the last months
of h'.r :tr-^^:\.::'xy ir. a malarial locality*, moved to a healthy situa-
tion :■• ':>u ce.ivLTuJ. The nurse noticed that the new-bom child
•Aci-> .^'.-izud \\i:l: attacks of restlessness during the first week of
cxtra-iitvrirx life, and c\ident discomfort at a certain period
durin.; the <:a\ . As a malarial origin of the attacks u"as sus-
\)rr.U:<\. 'jiiir.:!! was administered to the mother, and in a short
tiiiKj tile iir'ant became healthy. Dr Harris at the same time
described a >imilar case yielding to tiie same treatment.

Aside, however, from the direct action of the malarial poison
upon the fetus /;/ i/rrn^ the existence of malaria in the mother
seems to ha\ e a deleterious influence on its growth and develop-
ment, riuis, Hompiaiii ** says that the children born of malarial
mothers very rarely reach 3250 <;m. (/.I/ lbs.) in weight or 50
cm. (19.7 in.) in len^^th, and Negri ^ obser\'ed 34 cases in preg-
nant women, of which 18 per cent, terminated by premature
exjjulsion of the fetus. The administration of quinin in laree doses
to the mother affected with malaria would, therefore, be called for.
and one need not be deterred from usin^r the drug by the fear that
once prevailed of so bringing on an abortion, for, as Tamier say's,
*' (juinin in this condition is the best prophylactic treatment
against abortion or premature labor."

Tuberculosis. — Considering the vcr>' large number of tuber-
culous women who become pregnant, it is an extraordinary fact

' ** Annales de (iyn.," viii, p. 31. * O/^, cU. n. 24.

■ •* Herlin. klin. Wochcns.," 1885, Aug. 24, Sept. 7.
* *' Annal. di Obstet.," vi, 42,46, 1884.
» ** Annal. di Obstet.," viii, p. 277.

THE DISEASES OF THE FETUS, l6l

that the direct transmission of the disease from the mother to
the fetus is an extremely rare occurrence. Runge ^ infected a
number of pregnant guinea-pigs with tuberculosis, but invariably
failed to find the characteristic bacilli in the fetal tissues or pla-
centa. Ballinger, Davaine, Brauell, and Wolff have all expressed
a decided disbelief in the existence of congenital tuberculosis,
and Jani's observations have already been referred to. But
Demme once found the tubercle bacillus in the macerated fetus
of a tuberculous woman, and on one occasion Johnc ^ discovered
tubercles in a still-born calf, in which he found the bacillus
tuberculosis. While, therefore, there is a remote possibility of
the passage of tubercle bacilli from mother to fetus, it must be
regarded as a very exceptional occurrence. ^

Septicemia. — The possibility of the transmission of septic
micro-organisms from mother to fetus has been denied by many,
but the occurrence of septic infection of the fetus in utcro has
been strongly affirmed by Koubassoff, Chambrelent, Pyle,
Mars, H. von Hoist, and others. Mars,'* of Cracow, injected
putrid solutions into pregnant animals, and found often the same
bacilli in mother and fetus. Dr. Pylc's observation on the body
of a fetus removed by Cesarean section from its mother, who
was dying of septicemia, has already been noticed ; and, finally,
von Hoist, ^ after an extensive search through medical literature,
asserts positively that, although intra-uterine septic infection of
the fetus is rare, it has undoubtedly occurred.

Ctiolera. — Tarnicr^ says that there is nothing to justify the
belief that cholera affects directly the fetus /// utcro ; and
Queirel'' asserts that it is doubtful whether cholera can be con-
veyed to the fetus, but, nevertheless, early abortion is the rule,
and if the child should be born near or at term it dies in a few
days.

Typtioid Fever. — The effect upon the fetus of typhoid fever in
the mother is, as a rule, disastrous, resulting in the expulsion of
the product of conception in about sixty-five per cent, of the cases,®
the elevation of the temperature, the alteration of the blood,
and the respiratory embarrassment (Tamier) being considered the

» Quoted by Ott, loc. at, a Quoted by Wolff, he. n't.

• Sec A. S. Warthin, ** Ectopic Gestation ; Tuberculosis of Tul)cs, Placenta, and
Fetus,'* "Med. News," Sept. 19, 1896; Birch- Hirschfeld, ** Beitr. z. path. Anat. u.
2ur allgem. Path.," 1891 ; *• Archiv f. Gyn.," B<1. xliii, H. i, p. 162.

* Abstract "Archiv de Tocol.,'* 1883, p. 380.

* Dissertation, Dorpat. 1884 ; Abstract " Centralblatt f. Gyn," 1885, p. 2CO.

• Loc. cit,

' ** Nouv. Archiv d*Obst6t. et de Gyn^c," April 25. 1887, p. i.
» Duguyot, " Th*se de Paris," 1879.
II

1 62 PREGNANCY.

causes of the abortion or premature labor. But that the disease
can affect the fetus itself has been shown by Neuhaus,^ who
found the specific bacilli of typhoid fever in the lungs, spleen,
and kidneys of a fetus expelled at the fourth month from a
woman who was convalescing after a- prolonged attack of the
disease.

Articular Rheumatism. — The consideration of this disease
among the infectious diseases is perhaps not yet entirely justi-
fiable. There are, however, two instances on record of the
transmission of the disease from mother to fetus — one described
by Pocock ^ and the other by Schaffer.^ In each a woman
affected with articular rheumatism at the end of pregnancy gave
birth to a child presenting, in one case at once, in the other at
the end of three days, all the symptoms of the disease.

Recurrent Fever. — Albrecht ^ has described three cases of con-
genital recurrent fever, and in the blood of one fetus he discov-
ered the spirilla.

Yellow Fever. — Dr. Bemiss,^ of New Orleans, says: '* The
pregnant woman being attacked by yellow fever and recovering
without miscarriage, immunity from future attacks is conferred
upon the offspring contained in the womb during the attack." If
this is true, it certainly seems that the fetus must have Hkewise
passed through an attack of the disease.

Non-infectious Diseases of the Fetus. — The infectious dis-
eases are transmitted from mother to fetus. The non -infectious
diseases have an independent origin in the latter. It appears
occasionally, however, as if a non -infectious di.sease occurring at
the same time in mother and fetus was transmitted from one to
the other. So, for in.stance, in the case described by Dohm,®
of a mother, affected in the last weeks of pregnancy with pur-
pura haimorrhagica, giving birth to a child presenting number-
less subcutaneous hemorrhagic extravasations, the fetal disease
seemed to be directly derived from the maternal affection ; but
it was the same cause — malnutrition — that produced the disease
in mother and child. So, in the case described by Strachan,''
the disease might at first seem to have been transmitted from
mother to fetus : A woman in the eighth month of pregnancy
was admitted to a hospital ward on account of acute pneumonia

» •• Berlin, klin. Wochens.," l8S6, p. 3S9.

^ London '• Lancet,"' 1S82, ii,p. 804,

» "Berlin, klin. Wochens.," 1SS6, S. 70.

* '• St. retersl)ur|jj nie.l, Wocliens., iSSo, No. iS, and 1SS4, p. 129.

^ See Parvin's ♦* Ol'stetrics," p. 222.

« " Archiv f. (;yn.," Bd. vi, S. 486.

7 " British Med. Jour.," 1886, ii, p. 860.

THE DISEASES OF THE FETUS. 1 63

of the left lung. Shortly afterward she gave birth to a child
that lived only a few hours, and which, after death, was found to
have also acute pneumonic consolidation of the left lung.^ But
the ingenious explanation of Geyl,^ who has observed several
undoubted cases of acute pneumonia /;/ titero, is no doubt cor-
rect. In these cases there has been some interference with the
oxygenation of the fetal blood, and the resulting asphyxia has
induced efforts at respiration, whereby amniotic fluid has been
drawn into the lungs and has there set up an inflammation.

Some of the diseases of the fetus owe their origin to a vitiated
condition of the maternal blood, or to an inherent weakness in
the building material of the fetus, as in cases of chronic systemic
affections of cither parent, or to a perverted nervous action in
the mother. There are others for which a cause is unassign-
able. Some of these affections may be passed by with a simple
mention. Such are inflammations of the serous membranes,^
and the resulting ascites, hydrothorax, hydrocephalus, due in
the majority of cases to syphilis, although there is one case * on
record of atresia vulva: et recti and a vesico-uterine and utero-
rectal fistula, where the urine escaped into the peritoneal cavity
through the Fallopian tubes and set up a violent peritonitis ;
certain skin diseases, as ichthyosis, alopecia, hypertrichosis,
albinism, purpura ha^morrhagica, and elephantiasis; ^ intra-uterine
brain disease,^ which may consist of sclerosis, atrophy, lack of
development, tumors, cysts, or inflammation of the membranes,
diseases of the liver, sclerotic or multicystic,*^ along with cystic
disease, or cirrhosis of the kidneys, and the many varieties of
congenital tumors, solid or cystic, malignant or benign, which
are better described in text-books on pathology or surgery, or
in connection with the study of dystocia. In addition to these
affections, however, that have been hastily passed over, there
are others deserving more consideration.

Rachitis. — Children have been born with the rachitic pro-
cesses in their most active stage, — that is, while the bones are
still soft and easily distortable, — or at birth the process has evi-
dently pursued a longer course, for the bones are abnormally

* The author has re|)orte(l a case of pneumonia in uttro in the ** Amer. Jour.
Obstet.," Nov., 1887 ('* Trans. Phila. Ohstet. Soc").

2 " Archiv f. Gyn.," Ikl. xv, 384.

* For a reference to endo- and j>ericarditis see Cniveilhier, quoted in ** Ann.
di Ostet.," July, Aug., 1887, p. 314; and for congenital valvular defect, diagnosti-
cated before birth, see *' Trans. Med. and Chir. Fac. , Marjland," 1884.

* Olshausen, " Archiv f. Gyn.," Bd. ii, S. 280.

* Duhring, ** Diseases of the Skin," p. 418.

* Ix)ndon ** Lancet," 1886, i, p. 220.

' ** Trans. London Path. Soc," vol. vii, pp. 229, 235.

PREGNANCY.

I the dcfornicd shapes that they hai

164

hard and thiclc. and set ii
acquired in titer o.

Schorlau' collected the records of forty-three cases of con-
genital rachitis, and added to the number two of his own ; while
Grafe * mentions the cases that have been described by Sande-
fort, Winckler, Schiiltz, Virchow. Kehm, and Fischer; and of
late years Fehling ^ and Hcnnig * have also described specimens
of fetal rachitis. The author has observed one case.

As the etiology of infantile rachitis is by no means clear, it

is all the more difficult to e.vplain the occurrence of rachitis in

iitcro. It may be said, however.

to depend upon some vice of

^^^^^^ nutrition, especially if the preg-

^^^^^^^^ nant woman is living under un-

^^^^^^^^ favorable conditions as to food,

^^^^^^^P I'ght, and ventilation ; but the

^^^^^^B fact that the mother has at some

^^^^^^^ time had rachitis herself, as evi-

^^^^^^^ denced by the shape of her pelvis,

^^^^^^^k seems of itself by no means to

^^^^^^^V predispose the fetus to the same

^^^^^^^B alTection. The appearance of a

-Av ^^^^^^^K rachitic fetus, especially in the

^k ^^^^^^^P higher grades of the disease,

^^^^^^^V is quite distinctive. It has an

^^^^^^B enlarged head, perhaps hydroce-

^^^^^^H phalic ; gaping sutures and fon-

^^^^^^^ tanels, a "chicken" breast, and

Sfe^^C a much distended abdomen ; the

W^^^^ extremities are short, thick, and

_^ often bent at an angle, or curved,

118— RmhiiJs conutniiB micro- ^^^ ^^^ joints are large and
mclieo (author's ease). prominent The spine is often

curved either laterally or an-
teroposterior ly. * The bones are either abnormally hard and
firm or so brittle that they are fractured by the slightest force.
This condition of the bones in rachitis may be stimulated by the
arre-st of bony development in cases of sporadic fetal cretinism.*
Bidder and Miiller have described bone diseases in the fetus
which appear to be varieties of rachitis.

■' Monalschr, f. Gcburtsh.," Bd. »x«, S. 401.

"Arehiv f. Gj-n.," Bd. »iii, S. 500. • Ibid.. B<l. i.

■' TrensBctioni of Meeting of German Naluratisis and Phyait

Anasarca. — General anasarca of the fetus is occasionally seen.
The distention of the fetal skin may reach such dimensions that
the expulsion of the child becomes exceedingly difficult.' Such
children are, however, usually bom prematurely from the fourth
to the eighth month, and are, as a rule, still-born, although cases
are recorded in which death only occurred some little time after
birth. The causes of this condition must be various. It has
been attributed to anasarca of the mother, to syphilis, to absence
of the thoracic duct ; ^ in one instance to leukemia of the fetus,*
in another to obstruction of the umbilical vein.' The serous
infiltration of the skin is usually accompanied by a collection of
fluid in the abdominal and pleural cavities, and the membranes
and placenta arc often markedly edematous.

Congenital Cystic Elepbantiasis. — In this disease there is a
great overgrowth of the subcutaneous connective tissue all over
the body, and at intervals in the hypertrophied tissue there arc
cysts varying in size. Malformations of a grave character are
commonly associated with the disease. On this account, and
because the subjects of tlie disease have all been born prema-
turely, the infants scarcely ever survive their birth. One child,
however, lived thirty minutes and another was twenty montiis

' Kdlkr, " Edinburgh Mfd. and Sutg. Jour.," April, 1855.
' "The DiKises of Ibc Fetus," B»lliintyne, Edinburgh, iSgS, I vols. Com-
plMe biblii^rnphy.

• KIcbs, '■ Prager mcd. Wochens.," 1878, No. 49.

* " Breslau« Kbn.," Hd. I, S. a6o.

1 66 PREGNANCY,

old when the case was reported. Ballantyne ^ has collected more
than eighteen cases of this very rare disease.

Spontaneous Fractures in Utero. — The fetal bones may be
broken by external violence, or a child may be bom presenting
numerous fractures, especially of the long bones, either recent
or already undergoing repair, without the history of an accident
of any kind to the mother during pregnancy. If in such cases
one can exclude a syphilitic osteochondritis, with a separation
of the epiphysis and diaphysis, or an injury to the child during
labor, there must have been a rachitic condition of the bones or
an arrest of ossification, to allow of fracture by the slight force
which could be exerted by the fetal muscles or the pressure of
the uterine walls. Link,^ however, describes a case of numerous
fractures /;/ iitcro of the ribs, clavicle, and extremities, in which
syphilis, rachitis, and chronic parenchymatous osteitis could be
excluded, and ho, therefore, concludes that these fractures were
caused by an " unknown intra-uterine fetal bone disease,*' in
which the bones became soft and brittle. A similar bone disease
has been described by Schmidt.

Luxations and Ankyloses. — Luxations affect females four
times as often as males, ^ and are much more common in the
lower than in the upper extremities. An apparent ankylosis *
after birth occasionally appears when, in breech presentations,
the presenting part has remained a long time in the cavity of the
pelvis. The lower limbs remain in the position — of flexion of
thighs upon abdomen and extension of legs upon the thighs —
that they occupied /// titcro, and it is impossible for a while to
restore them to a proper position.^

Intestinal Invagination. — Lauro ^ has described a double
invagination of the descending colon during intra-uterine life.

Intra-uterine Amputations. — The complete severance of a
portion of a limb /;/ utero is an extremely rare occurrence. "^ The
explanation of the amputation is most frequently the presence
of constricting amniotic bands, — a condition more fully described

^ •* Diseases of the Fetus," Edinb., 1895, 2 vols.
2 " Archiv f. (iyn.," Hd. xxx, 2, p. 264, 1S87.
' Taniier et Budin, loc. at.

* Lefour, '* Presentation du Si^^e dccompl^tt* Mo<le des Fesses," Paris, 1882.

* The fixation of the rnnl)s or trunk in abnormal ])osilions by muscular contrac-
tion may occur/;/ uft-ro durin*^ jires^nancy, as in tiie interesting case of '* contracture**
in utero (Ribemont-Dessaignc, ab>tract in " Nouv. Archiv d'Obst^t.," Sept., 1887).
In this connection the student should con^^uU also the paper by Matthews Duncan on
•' Extensions and Retroflcxionx of the I'etus, especially of the Trunk, during Preg-
nancy " (•* Trans. London ()l)stel. Soc./' xxvi, 1SS4, p. 206).

® ** Annali di ()>tet. e (iinecol.." Lu^lio A«^osto, 1S87.

' For an extensive bil)lio^raphy see *' Tariiier et Budin."

THE DISEASES OF THE FETUS, 1 67

under the Pathology of the Amnion. But this explanation will
not suffice for all cases ; it has been demonstrated that a gan-
grenous process ^ at a certain point in the limb may determine
an amputation, just as it would in extra-uterine life, or that a
peculiar morbid process 2 may produce a constriction from the
circular contraction of connective tissue at a certain point, or,
again, that an amputation * may follow a fracture. The ampu-
tated part may float loose in the amniotic liquid, may possibly be
absorbed if detached early in embryonal life, or may be attached
to the sound portion of the limb by a filament more or less bony.
Petal Traumatism. — The position of the fetus in utero
secures it the greatest possible immunity from external vio-
lence, but it may experience injuries of the gravest nature,
either in connection with serious injury to the mother or occa-
sionally with very shght evidences of violence to the maternal
tissues. Thus, in cases of gunshot,^ stab,^ or other perforating
wounds of the abdomen in pregnant women, the fetus has like-
wise been severely and fatally wounded. Also, in the perform-
ance of celiotomy,^ by a mistaken diagnosis the trocar that was
plunged into what was thought to be an ovarian cyst has pene-
trated the fetus, and wounds have been inflicted by both sharp
and dull instruments ignorantly used to bring on an abortion or
in the hands of physicians who overlooked the condition of
pregnancy. On the other hand, as instances of fatal injury to
the fetus without apparent injury, externally, at least, to the
mother, might be cited those cases of Mascka*^ and Gurlt,® in
which the cranial bones of the fetus were fractured by the mother
falling from a height, or the case described by G. von Hoff*-
mann,^ of a woman in the fifth month of pregnancy who threw
herself out of a fourth-story window and was killed by the fall,
although she exhibited no signs of external injury ; the uterus
was uninjured, and the fetus externally was apparently unharmed,
but on opening its abdomen the liver was found to be almost dis-
integrated. The case, however, reported by Dr. Lumlcy,^ ® shows

^ Chaussier, " Procds verbal de la Distribution des Prixes ^ la Maternity," 1822.
' Kristeller, ** Monatschr. f. Gcburtsh.," Bd. xiv, p. 817.
» Martin, " Gaz. H6bdom.," 1858, p. 384.

* Hays, **Ann. de Gyn.," 1880, xiii, p. 153.

* Fennell, " Trans. X. V. Path. Soc," iii, 249; Tamier et Budin, loc, cit.^ p.
345 ; Guelliot, " Gaz. des Hdp.," 1886, p. 405.

® Goodell, " lessons in Gynecology,'* p. 352.

^ " Prager Vierteljahrschrift," 1857.

* ** Monatsch. f. Geburtsh.," 1857, p. 343.

® " Wien. med. Presse," xxvi, 1885, Nos. 18, 20, etc.
»o *«N. Y. Med. Rec," 1886, p. 359.

1 68 PREGNANCY,

more clearly ho^y slight violence to the mother may be fatal to
the fetus: A.^^iugnant woman, within ten days of term,
attempting to enter a doorway, slipped and struck the left lower
portion of her abdomen against the edge of the door. The
movements of the child thereupon ceased, and eight days after-
ward a dead fetus was born with a fracture of the left frontal and
parietal bones of the skull. One of my patients was thrown
from a carriage two months before her delivery. Her infant,
otherwise healthy, had a fractured clavicle, almost entirely healed,
but with a large mass of callus about the site of fracture.

These cases of fetal injury are not only interesting from their
rarity, but they are also important from a medicolegal point of
view. Thus, Gorhan ^ records the death of a fetus from violence
done the mother at the hands of another woman in the course of
a brutal quarrel between two sisters-in-law, during which the
pregnant woman, being at the time in the sixth month of
gestation, was thrown to the ground and stamped upon by her
infuriated relative. Two months afterward a dead fetus was
bom, corresponding in development to the sixth month of
pregnancy, and exhibiting a transverse fracture of both parietal
bones. It might be important to distinguish injuries experienced
during labor, as fractures of the extremities or of the spine, ^
or depressions of the skull, ^ from the effects of traumatism during
pregnancy.

Conditions of the Mother Which Injuriously Affect the
Fetus. — ^The Influence of Maternal Fever upon the Fetus. — The
well-known experiments of Rungc,** published in 1877, were for
some time accepted as conclusive proof of the great danger to
the fetus of high temperature in the mother. Pregnant rabbits
placed in a hot box until their body -temperature had risen to
105.8° usually died, and almost invariably the fetuses were found
dead upon opening the animal's body immediately after its re-
moval from the box. But in 1883 Doleris^ showed that if the
temperature of the animals was slowly raised to 105° or 106°,
and not within an hour, as in Rungc's experiments, they seemed
to bear it without much inconvenience, even if long continued,
and, if pregnant, their young remained perfectly healthy. These

^J. Taber Johnson, "Trans. Am. (iyn. Soc.,'' vol. iii, j). 107.

^' '* Wien. nicd. Pnssc," xxvi, p. 370.

^ There arc, however, two recorded rases of this injury occurring from
traumatism (hiring ])ret;naiicy.

^•'Arcliiv f. (iyn.," IM. xii, \\ 16; Hd. xiii, ]). 123.

■'' *• Comptesrcnd. hebd. Seances de hi Sociele de liioloj^ie,'' Xos. 28, 29. Doleris*
results were confirmed by exjx-rinipnts of Dore (•' Arch, de Tocol.," 1SS4, ]>, 14I),
and quite recently by Negri (see abstract in *' Xouv. Arch. d'Obstet. et de Gyn6c. ").

THE DISEASES OF THE FETUS, 1 69

results were confirmed by Runge^ in a seconc, of experiments,
in which he found, however, that if the animai ^ w^mperature was
raised, even very gradually, to 109.4°, there occurred the same
symptoms — death of the fetus and heat-stroke of the mother —
as though the temperature had been quickly raised to 106°.
Preyer^ has also shown that the fetus is capable of enduring a
much higher temperature than was formerly supposed, for in one
instance he actually observed a fetal temperature, in a guinea-pig,
of 111.2°, taken /// a7to, the fetus living nine minutes, or until
the cord was severed and it was removed from the uterus. In
view, therefore, of these experiments, it seems necessary to modify
the views formerly entertained, that the existence of fever in the
mother must of itself necessarily threaten the life of the fetus,
unless, indeed, the temperature should rise suddenly, as in the
case of brain-tumor described by Runge, or in cases of recurrent
fever recorded by Kaminski,^ or else should reach an extreme
height, as it might in insolation.

As to the treatment of fever in pregnant women with a view
to its influence on the fetus, no special measures are required
so long as the temperature rises gradually and remains under
105°, but above this point the danger to the fetus begins (Kam-
inski), and active antipyretic treatment is required. Should a
pregnant woman die with a temperature as high as 109°, the
performance of postmortem Cesarean section would be useless,
for the fetus would inevitably die first, having no means of getting
rid of its extra heat by radiation. The operation would likewise
be fruitless in a case of death after a very sudden rise of tem-
perature (Runge).

The Influence of Maternal Emotions upon the Fetus. — Maternal
emotions and impressions may affect the embryo or fetus. Many
cases of mental peculiarities or diseases, or of physical defects, that
have been attributed to a strong impression upon the mother
during pregnancy, are no doubt to be explained by the existence
of some systemic disease, as syphilis, nephritis, diabetes, cancer,
or chronic lead-poisoning in either father or mother ; by an arrest
of development ; by mechanical disturbance of the ovum, or, in
the case of intra-uterine amputations, by the formation of amniotic
bands or the disposition of the cord ; but there still remain well-
authenticated cases of congenital defects or peculiarities,"* which
bear too startling a resemblance to the cause of the impression

1 " Archiv f. Gyn.," Bd. xxv, S. I.

* ** Physiologic des Embn'o," Leipzig, 1884.
»**St. Petersburg med. Zeitung," 1868, 1 17.

* See the very interesting paper by Dr. Fordyce Baker in ** Gynecol. Trans.,"
vol. xi, 1886.

I70 PREGNANCY,

upon the mother during pregnancy to be dismissed as mere coin-
cidences. One of my patients, less than six weeks pregnant,
was, on one occasion, seized by the ear and dragged about the
room by her enraged husband. The child born at term had a
triangular piece lacking from the lobe of the corresponding ear.

A strong emotion on the part of the mother may be imme-
diately fatal to the fetus, as apparently happened in a case
reported by Hayes. ^ The idiocy of Barnaby Rudge due to
maternal shock and fright is a fiction founded upon fact.

There is no question that certain maternal conditions may so
modify the blood in its capacity of a bearer of oxygen and
nutriment to the fetus as to seriously interfere with the latter*s
health, if not to destroy its existence. Such is undoubtedly the
case in pneumonia of the mother, which can prevent a proper
aeration of the maternal, and consequently of the fetal, blood,
and may so bring about complete asphyxia of the fetus, or may,
perhaps, result in inspiratory efforts /;/ utcro^ the inspiration of
liquor amnii, and a subsequent development of pneumonia in the
fetus itself 2 Whatever the cause of death, pneumonia in the
mother is exceedingly fatal to the fetus.

In infectious diseases also the development of specific micro-
organisms in the maternal blood may so alter its normal con-
stitution as to render it unfit for the respiratory and nutritive
needs of the fetus, this condition of the blood, constituting
perhaps the chief peril for the fetus, for ** the fever is usually
the least of the dangers to the fetus in these (infectious) dis-
eases " (Rungc). riie occurrence of cxanthematous and of
hemorrhagic cnciometritis during the course of certain infectious
diseases has been considered under the head of Decidual Endo-
metritis.

Icterus Qravidarum in its Influence on the Fetus. — The occur-
rence of this comparatively rare disease endangers to a high
degree the life of the fetus, either by bringing on an abortion or
by first destroying the life of the fetus through the poisonous
action of the bile-salts, ^ or, perhaps, by the induction of cholemic
convulsions.^ Thus, Spath^ describes 8 cases, in 4 of which
the fetus was born dead ; and Frcrichs^ mentions 3 cases,
all fatal to the fetus. Saint VeF has described an epidemic

* ** Lancet," vol. ii, 1S74.

* See Inspiration Pneumonia.

* Valenta, ** Oesterreichische Jahrh. ," xviii, 1S69, S. 163.

* .Stumpf, "Archiv f. Gyn.," IJd. xxviii, H. 3.
» "Wiener med. Wochens.," 1854, S. 757.

- Lebcrkrankheiten," 1858, Bd. i.
," 1862, p. 538.

THE DISEASES OF THE FETUS, 171

of jaundice on the island of Martinique, during which, of 30
pregnant women affected, 20 were delivered prematurely, and
of these 20 children 19 were either still-bom or died shortly
after birth. Bardinet^ has also recorded the birth of 6 dead
infants out of 13 pregnant women who were suffering from
jaundice during an epidemic of the disease in Limoges. Fre-
quently as the bile-salts must traverse the uteroplacental septum
and enter the fetal circulation, as evidenced by the high per-
centage of still-bom children in women affected with jaundice
during pregnancy, the coloring-matter of the bile seldom stains
the fetal tissues. Lomer^ collected 56 cases in which naturally
colored children were born of jaundiced mothers, and 43 more
in which the color of the child was not mentioned, so that
it was presumably natural ; and to these might be added another
case described by Parrish. There are 6 recorded cases, however,
in which the fetus or the whole ovum was undoubtedly jaun-
diced (Lomer).

Eclampsia. — It has been estimated that about one-half the
children are still-born after the eclampsia of pregnancy or labor.
The cause of the fetal death is not altogether clear, for it might
with equal plausibility be laid to the presence of too much car-
bonic-oxid gas in the matemal blood, to the stagnation of the
blood-current during a convulsion, or to the presence of excre-
mentitious matters in the blood.

The Death of the Mother. — The effect of the death of the
mother upon the fetus is ultimately fatal, but as to the length of
time that life can continue m the fetus after it is extinct in the
mother there is considerable difference of opinion. Kergaredec's
view that twenty -four hours might elapse between the death of
the mother and the fetus is, of course, preposterous. There is
on record, however, a well -authenticated case of the extraction
of a living child from the womb of a woman who had been dead
two hours. ^ Tamier "* also performed a postmortem Cesarean
section upon a woman who during the Commune in Paris had
been killed by a stray bullet in the wards of the Matemite, and
extracted a living child, certainly three-quarters of an hour —
perhaps an hour and a quarter — after the death of the mother.
Numerous other instances are recorded of postmortem Cesarean
operations, or the extraction of infants per vias naturalcs^ at inter-
vals of time longing from a few minutes to a half hour after the
death of the mother. The remarkable survival of the fetus under

» "Union M6dicale,'* 1863, Nos. 133 et 134.

« "Zeit. f. Geburtsh.," xiii, p. 169, 1886.

' Hubert, ** Trait6 d'Accouchements," vol. ii, p. 160.

* "Tamier et Budin," ii, p. 571.

conditions which would seem to make life impossible is explained,
perhaps, by the cases of children bom asphyxiated, whose liearts
continue to beat, although they do not breathe for a long time
after birth, or by the experiment performed by Haller ^ of forc-
ing a bitch to give birth to her pups under water, where they
crawled about and lived for half an hour.

The Death of the Fetus — The death of tlie fetus in uU-ro
may be due to many cau.ses. It may be the result of injuries,
deformities, or diseases in the fetus itself or in its appendages,
the membranes, and the placenta. It may be due to inherent
weakness in either the ovule or the spermatic particle, which
does not prevent conception, but which renders the embryo
incapable of development beyond a certain point ; or it may be
the consequence of a misplaced ovum, as in tuba!, ovarian, and
abdominal pregnancies. The condition of the maternal blood,
the existence of a very high
temperature in the mother,
and perhaps strong emo-
tions, must also occasion-
ally be held responsible for
the destruction of feta! life.
All these conditions, how-
ever, have been or will be
considered in their appro-
priate places ; but it remains
to notice the effect that the
death of the fetus produces
upon the mother, the signs
by which it may be possible
Fig. 120— Two yeurs ill the abdomen (Baer), to determine whether the
fetus in Httro be alive or
dead, the habitual death of the fetus in ultra, and the changes
tJiat ensue after death in the fetus itself

The effect of the death of a fetus upon its mother is ofien
nil. There may, however, be depression, loss of appetite, and
chilly sensations. When the dead body undergoes putrefactive
changes, or when, the soft parts being absorbed, there is an
attempt to get rid of tiic fetal bones by ulcerative processes into
the bladder, vagina, or rectum, or externally through the abdom-
inal walls, the mother's health and safety are seriously endangered.
Thus, after ectopic gestation the dead fetus may remain for an
indefinite period within the mother's abdomen, without giving
rise to greater inconvenience than would be caused by the

' ■' Elim. Physiol.," vol. iii. p. 314, quoted in " Tamier el liudin," ef. t
P-S70.

THE DISEASES OF THE FETUS.

enlargement of the abdomen ; but should the germs of putrefac-
tion gain access to the dead body, as they may by reason of
the contiguity of the inttistincs (Litzmann), then a general sup-
purative peritonitis may be developed and rapidly prove fatal.
So, too, in the retention of blighted ova' or in cases of missed
labor* there is usually no evidence of serious harm to the mother
until the putrefaction of the dead body begins, when there may
be shortly manifested all the symptoms of septicemia, unless
the uterine cavity be speedily cleared of its contents and well
disinfected.

It is by no means an easy matter to determine whether or
not the fetus has ceased to live. If its death should have
occurred during the early part of pregnancy, the uterus will
usually cease developing and the circumference of the abdomen

\vill no longer increase steadily from week to week ; the breasts
will soon become flabby, although it is not rare for milk to ap-
pear for a time after the death of the fetus ; the woman may
complain of subjective symptoms, as a feeling of weight and dis-
comfort in the hypogastric region (Lusk) ; but the doubt will
usually soon be solved by the expulsion of the ovum. •' It is
not rare for the lacteal secretion to be established three or four
days after the death of the fetus, with all the phenomena char-
acteristic of that function after delivery" (Tamier). Should the

' Sf* Gehrung, " Weekly Med. Kevitw," Chicago. l88s, p. 13I ; " Westmina-
ler Ilospilsl Reports," 1885,!. 119; "TokioMed. Joum.," 1886, No. 439. Graefe,
in Rule's '■ FuUchrifl " ; SlSger, Inang-Diss., Brm, 1H95.
« «Dd Art of Midwifery.'' 1886, p. 304.

174 PREGNANCY.

fetus die in the later months of pregnancy, the movements,
theretofore perhaps active, are no longer felt by the mother, and
the fetal heart-sounds are no longer heard. Neither of these
signs, however, is entirely reliable, for the woman's statement
is not always perfectly credible, and it is impossible occasion-
ally to hear the fetal heart-sounds, although the child is alive
and well. The urine of the mother commonly undergoes a
change after fetal death. Albuminuria sometimes disappears
when the fetus dies. On the contrary, I have seen albuminuria
appear in consequence of fetal death. Peptonuria may be looked
for if there is decomposition of the fetal body, and acetonuria, it
is claimed, is an invariable consequence of a dead fetus in
utero.^ Negri 2 on one occasion was able to make the diag-
nosis of fetal death during pregnancy by abdominal palpation,
the fetus presenting a rather confused outline and giving rise,
upon pressure of the mother's abdomen over the region of the
fetal head, to an indistinct crepitus. During labor a doubt will
often arise as to whether the fetus is dead or alive, and upon the
decision arrived at will often depend the performance of em-
bryotomy or of a more conservative operation. Under these
circumstances it has been suggested by Cohnstein^ and Feh-
ling'* that if the temperature of the uterus be found no higher
than that of the vagina, the child may safely be pronounced
dead ; for the living fetus, having a higher temperature than its
mother, will impart some additional heat to the maternal struct-
ures about it. Priestley^ more practically suggests that the hand
be introduced into the uterus in order to feci in the precordial
region for the impulses of the fetal heart, or to feel the pulsa-
tions in the cord.

After death the fetal tissues in time saponify (adipocere),
jxirtially calcify, mummify, or else arc totally or partially ab-
sorbed. The phenomena seen shortly after death consist of
maceration and putrefaction. Before the second month the pro-
duct of conception may be entirely absorbed. After that time
the changes that take place depend to some extent upon the
position of the fetus. Within the uterus the dead fetus is first
macerated, becoming bloated in appearance, with a grayish-
colored skin deprived of its epidermis in spots of greater or less

' Acetonuria was found 9 times in 130 prej^nant women, and in each of the 9
cases it was dt-monstrated thai the woman was carrying a dead fetus. Vicasella,
**\Vien. mod. Presse," 1894, j). 205.

2 "Annali di Ostetricia," May, June. 1SS5, p. 223.

« *'Archiv f. (lyn.," Bd. iv, H. 3.

* Ibid.^ Bd. vii, S. 143.

6 ♦• Lancet," Jan. 23, 1887.

THE DISEASES OF THE FETUS, 1 75

extent ; the head is enlarged, the cranial bones are loose
under the scalp, and the tissues become so soft and friable that
very slight force is sufficient to detach the limbs from the body.
Should air be admitted to the fetus in this condition by rup-
ture of the membranes, decomposition rapidly ensues. The
other changes that affect the tissues after death in utcro are a
kind of saponification, and possibly mummification, in which
latter state they will remain for an indefinite period without
change. It is in abdominal pregnancies that the dead fetus be-
comes converted into a so-called lithopedion, which consists not
of a calcification of the whole mass, but (i) of a calcification of
the membranes after absorption of the liquor amnii ; (2) of a cal-
cification of the membranes and those points on the fetus where
the membranes adhere to the fetal surface ; or (3) of a deposition
of lime in the vemix caseosa after the membranes have been
ruptured and the fetus has escaped into the abdominal cavity.^
The fetus in the abdominal cavity may undergo all the other
changes that have been described, including putrefaction, and,
in addition, the soft parts may be absorbed, the bony skeleton
remaining as a foreign body in the abdomen until it is discharged
piecemeal, perhaps through openings into the bladder, intestines,
rectum, uterus, and vagina, or externally through the abdominal
walls.

The Habitual Death of the Fetus — There are women who
conceive, perhaps frequently, but who in two or more successive
pregnancies, usually at the same period in each, give birth to
dead children. It is important in these cases to learn, if pos-
sible, the cause of the repeated fetal death, for upon it depends
the treatment that may be adopted to secure the birth of a living
child.

Although by no means the only cause of the habitual death
of the fetus /;/ utcro, s)^hilis is by far the most frequent.
According to Ruge's^ estimate, eighty -three per cent, of repeated
premature and still-births are to be explained by the existence of
syphilis in one or both of the parents. But there are many cases
in which syphilis can with certainty be excluded, and in which
the death must be ascribed to one of the other conditions that
modern investigation has shown to be occasionally responsible
for a repeated interruption of pregnancy.

Certain Conditions of the Uterus which Interfere with the
Development of the Fetus. — There are no reliable statistics in
regard to the relative frequency of the causes, other than s)^hilis,

> KUchenmeister, ** Archiv f. Gyn.," Bd. xvii, p. 153.
2"Zeit. f. Geburtsh.," Bd. i.

176 P/^EGiVANCY.

of habitual death of the fetus, but I should be inclined to place
first chronic endometritis and chronic metritis. Schroeder,"
amony others, speaks of the frequency with which a chronic
endometritis can bring about an interruption of pregnancy, either
by effusions of blood into the hj'pcremic mucous membrane, and
the consequent excitation of muscular action in the uterus, or
by an active growth of the decidua and the diversion of the nu-
tritive blood-supi)ly from the fetus to the uterine mucous mem-
brane.

Abarbanell - first called attention to chronic metritis as a
cause of habitual abortion, from the excessive development of
fibrous tissue in the body of the uterus, which by loss of elas-
ticity would interfere with a sufficient dilatation of the uterine
cavity. Such, perhaps, is the explanation of Baudelocque's
case,* in which, after a Cesarean section, a woman successively
jfave birth to four children at the seventh month of pregnancy.
In two cases under my observation an ill-developed uterus was
the cause of repeatcil premature births. In one the woman gave
birth to thirteen children at the sixth month, none of which sur-
vived. In the other there were three premature births before the
children were viable. In this woman menstruation began in the
eighteenth year ; there were long periods of amenorrhea, and a
vaginal examination before marriage revealed an infantile uterus.

Alterations in the Maternal Blood that are Fatal to the
Fetus. — Scanzoni * pointed out that a high grade of anemia in
a pregnant woman might be fatal to the fetus. The anemia may
be due to an exaggeration of the hydremia which is character-
istic of pregnancy, or to the development of pernicious anemia ; *
to sudden loss of blood, or to lack of proper or sufficient food.
To this last cause may be attributed the lai^e number of abor-
tions and .still-births that occurred during the siege of Leyden
(Hoffmann), or in Germany during the year 1836, when the
crops failed (Niigelc), and during the siege of Pans (Priestley).

Plethora in the mother, on the other hand, has not such an
unfavorable influence upon the fetus, for the very existence of
pregnancy usually corrects the evil. It is possible, however, that
this condition might prnve a predisposing cause to effusions of
blood into the membranes or placenta, especially at a time corres-
ponding to a menstrual period.

THE DISEASES OF THE FETUS. 1 77

The Effect of Chronic Diseases of the Mother upon the
Fetus. — ^Women affected with tuberculosis,^ cancer, or chronic
malarial poisoning ^ may give birth to a succession of dead chil-
dren. Icterus gravidarum also, whether simple, epidemic, or
pernicious, might be a cause of repeated fetal death, although the
course of the last two is usually too rapid to allow of repeated
impregnation.

Nephritis. — Fehling^ has called attention to the influence of
maternal nephritis as a cause of repeated still-births. The death
of the fetus is often the result of the morbid condition of the
blood-vessels in the maternal portion of the placenta, corre-
sponding to the condition found in the lungs, brain, and other
organs in chronic nephritis. The brittleness of the capillary
walls leads to apoplexies and to the formation of large infarcts
in the intercot>'ledonic spaces, which so compress the neighbor-
ing placental villi that they can not perform their physiological
functions. The effusion of blood may also cause a premature
detachment of the placenta.'*

Charpentier and Butte^ have shown that an excess of urea in
the maternal blood may prove fatal to the fetus by the direct
poisonous influence of this substance. Disturbances in the
maternal blood-pressure (Runge) and insufficient oxygenation
of the maternal blood may also occasionally be responsible for
the fetal death.

Diabetes. — This disease seems to have a most disastrous in-
fluence upon the fetus. Matthews Duncan^ collected the record
of 19 pregnancies occurring in 17 women, in 7 of which the
fetus died in the latter part of pregnancy. In 2 cases the children
were feeble at birth, and i child was diabetic.

Chronic Poisoning. — Constantin Paul "^ was the first to point
out the evil influence of saturnism upon pregnancy. Of 123
conceptions observed by him in women the subject of chronic
lead-poisoning, 64 ended in abortion, 4 in premature labor, and
there were 5 still -births ; only 10 children passed the age of
three years. These observations have since been confirmed by
Roque® and Rennert.®

* Tamier et Budin, op. cit.y p. 89.

* Borapiani, ** Annal. di Ostet.," vii, 42, 46; discussion of Dr. .Schrady's paper,
«* Med. News,*' 1885, i, 358; Negri, ** Annal. di Ustet.," viii, p. 277.

* "Archiv f. Gyn.," Bd. xxvii, p. 300.

* Winter. " Zeit. f. Geburtsh.," Bd. xi, S. 398.

* "Trans. Ninth International Medical Congress."

* **Ob8tet. Trans.,*' London, vol. xxiv, p. 256.
^ Tamier et Budin, op. cit.^ P- 3i-

» ** Thdse de Paris," 1873. « ** Archiv f. Gyn.," Bd. xviii, p 109.

178 PREGNANCY.

It has also been asserted that female workers in tobacco are
peculiarly liable to abortion or to still-births (Jacquemart, Kos-
tial), but there is difference of opinion on the subject. Professor
Hunter Maguire, of Richmond, Virginia, kindly inquired for
me of some of the largest tobacco-manufacturers in that city
as to the effect of tobacco on the pregnant women in their employ.
There was no evidence of a deleterious influence upon pregnant
women or their offspring.

Causes of Death Residing in the Fetus Itself. — It has been
already stated that syphilitic disease of the fetus or ovum is by
far the most frequent cause of habitual death ; but there may
be other causes residing in the fetus itself which remain after the
rigid exclusion of syphilis. It is well known that deformities
may be hereditary in certain families, carried through every
member of several generations.^ A woman might, therefore,
give birth to a number of children, each presenting the same
deformity, grave enough perhaps to destroy life.^ Leopold*
discovered a curious affection to be the cause of death in several
dead fetuses born successively of one woman. This consisted of a
thickening of the fibrous and muscular coat of the umbilical vein so
that its caliber was seriously diminished. Syphilis was excluded.

The Causes of Fetal Death Referable to the Father. — In
case it is impossible to attribute the habitual death of the fetus
to inherent defects or to ill-health of the mother, the explanation
may be sought in the condition of the father. He may be too
old or too young to furnish a fecundating germ of sufficient
vigor to enable the fetus to reach maturity ; or he may be the
subject of some chronic debilitating disease, as nephritis, dia-
betes,'* phthisis,^ cancer, 6 or chronic lead-poisoning,*^ which
may not affect the fecundating power of the spermatic particle,
but renders it incapable of performing its part in building up
a healthy embryo. Thus, Priestley tells of a healthy young
woman, whose husband had albuminuria, giving birth first to a
sickly infant and afterward aborting in three successive preg-

1 "British Med. Jour.," Jan. 22, 29, 1SS7 ; "Am. Jour. Obstet.," 1886, p.
1 108.

2 A lioness in the Philadelphia Zoological Garden has j^iven birth, on three sep-
arate occasions, to cubs that were deformed about the jaws and palate, and lived only
a few moments after birth. This is said to be the rule with lionesses in captivity.

» ** Archiv f. GynSk.," Bd. x, p. 191.

* Priestley, " Lumleian Lectures on the Pathology of Intrauterine Death,*' rep.
from "British Med. Jour.," 1887, p. 8.

• D'Outrepont, ** Neue Zeit. f. Gcburlsh," 1838, Pd. vi, p. 34.

r^memier, "Diet. Encyc. des Sc. m6d.," art. " Avortement," vol. vii,

n Paul, loc. cit.

THE DISEASES OF THE FETUS, 1 79

nancies, or until her husband succumbed to uremia. D' Outre-
pont also has related the following case : A woman married to
a phthisical man became pregnant five times, in each instance
giving birth to a dead child at the eighth month. Remarried to
a healthy husband, she gave birth to four healthy infants in
succession. Paul, in 39 pregnancies in 7 women whose
husbands were afflicted with saturnism, observed 11 abortions
and I still-bom child, while of the 27 children bom alive only
9 survived early infancy.

The Habit of Qivins: Birth to Still-born Children. — If one
can exclude all the causes in the mother that have been enumer-
ated as responsible for the death of the fetus, if there is no sign
of abnormality or disease in the fetus or ovum, or if there is
nothing in the condition of the father that might account for the
repeated still-births, then their occurrence may be attributed to
a habit of the mother of giving birth to dead children. Such
cases are extremely rare, as may be imagined, but are by no
means unknown. Two examples may be cited : A woman ^
subjected to a severe fright in the last month of pregnancy after-
ward gave birth to a dead child. In twelve successive preg-
nancies she gave birth to dead children at the seventh month.
The mother of Hohl ^ gave birth alternately to living and dead
children. The first child was living and healthy, the second
dead, and so on until the tenth pregnancy, when so certain was
the lady that her child would be born dead that she provided
nothing for it. It was born alive, however, and was no other
than Hohl himself

The Diagnosis of the Cause of Repeated Still-births. — The suspi-
cion of syphilis in the parents will usually first enter the mind
of a -practitioner who meets with cases of habitual death of the
fetus; but, aside from the possible injustice of such a suspicion,
it may suggest inappropriate treatment. It is, therefore, im-
portant to discover the true cause of the inability of the woman
to bear a living child, for the treatment that may be adopted to
prevent a repetition of the still-births must differ radically with
each of the many causes that have been enumerated above.
Syphilis, as by far the most frequent cause of habitual death of
the fetus, must be first excluded before another cause is sought.
But this is by no means always an easy matter. It frequently
happens that the history of the parents is obscure, and that the
fetus is expelled already macerated or with no distinctive marks
of disease upon its body. In such a case a careful examination
of the fetal body will usually reveal unmistakable evidence of the
existence of syphilis.

1 Hayes, London ** lancet,'* 1874, vol. ii. ' Tarnieret Budin, op. cit.y p. 36$.

l8o PREGNANCY,

To determine the other causes of repeated fetal death, endo-
metritis and metritis should be looked for. An anomalous
condition of the uterus may be discovered. The blood of the
mother should be examined for plethora or anemia. The lungs
should be examined for phthisis, and the urine for sugar or for
albumin and casts. The history of the patient may point to the
existence of malaria or of chronic lead- or tobacco-poisoning.
Physical signs may denote a cancer, or there may be unmistak-
able jaundice. The fetus itself must be examined for some
hereditary defect, and the cord for stenosis of the umbilical vein.
Finally, the condition of the father must be inquired into. If
all other signs fail, the diagnosis must rest upon a habit or upon
a hereditary predisposition of the mother.

The Preventive Treatment of Habitual Death of the Fetus. —
In the case of syphilis of the parents an appropriate antisyphilitic
treatment should be administered. So frequently is an antisyphi-
litic treatment successful in these cases that certain writers have
recommended the administration of potassium iodid or mercury
to every woman who was in the habit of giving birth to dead
children. If a woman first comes under observation after im-
pregnation has occurred, mercury and iodid of potassium should
be administered throughout the whole of pregnancy if there is
reason to suspect that the fetus may be syphilitic.

If there should be a chronic endometritis, a curetment may
be followed by conception and a normal pregnancy.^ A cor-
rection of a displacement of the uterus or a repair of a lacerated
cervix may be followed by the same result. In anemic women
a tonic treatment will often be followed by the birth of a vigorous
infant. Plethoric patients, on the other hand, would be bene-
fited by increased exercise, by frequent depletion, and by a
restricted diet. Phthisis, cancer, diabetes, or nephritis in the
mother renders the prognosis for the fetus grave. In chronic
malarial, lead-, or tobacco-poisoning the elimination of the poison
should enable the woman to bear a^living, healthy child.

A chronic, incurable disease in the father may so deteriorate
the quality of the spermatic particles that, while conception may
occur, the development of the embryo is impossible. Should
his condition, however, admit of improvement, the male fertil-
izing element may gain sufficiently in vigor to perform its part
in the growth of the fetus.

There are women who carry a living child up to a certain
period of pregnancy, but if allowed to go to term give birth
repeatedly to dead infants. Thus, Tarnier^ tells of a woman,

» Schroeder, " Gcburtsh.," 8th ed., p. 405. 2 i^^. cit., p. 365.

THE PHYSIOLOGY OF PREGNANCY. l8l

apparently in good health, who gave birth to thirteen dead
children successively, although it was demonstrated that the
fetus was in each instance alive until the last month of pregnancy.
The same authority cites another instance of a woman who in
seven successive pregnancies experienced the active movements
of her child until within fifteen days of the normal time of
delivery, and yet always gave birth to a dead infant. In such
cases as these it is evident that the birth of a living child could
be secured by inducing labor at a time before the period of
pregnancy at which the accustomed death of the fetus occurred.

CHAPTER VI.

The Physiologfy of Prcgfnancy.

The whole organism shows alterations in sympathy with the
development of the pregnant uterus ; but, as might be expected,
these alterations are most striking in the genital region.

The uterus shows an extraordinary developmental change
in all its constituent parts. The vmscle-fibers hypertrophy until
they are eleven times as long and five times as broad as those of
the non-pregnant uterus. A multiplication of the fibers, a true
hyperplasia, has not been demonstrated. The connective tissue
increases markedly, sending in newly developed fibers between
the muscle-bundles and increasing in bulk by a serous infiltra-
tion. The peritoneal covering of the womb shows a true hyper-
plasia to enable it to keep pace with the growth of the uterus.
The development of new cells is not entirely uniform, so that
the peritoneum covering the womb varies in thickness. The
membrane is quite firmly adherent to the uterus except over the
lower uterine segment, where it is readily stripped off. The
blood-vessels develop rapidly. The arteries are vastly increased
in caliber and length and become extremely tortuous. The
uterine artery sends a large branch to the upper margin of the
lower uterine segment, and numerous smaller branches penetrate
the uterine wall, where in some situations they communicate
directly with the veins. At the placental site the arteries termi-
nate in the curling arteries of the uterine dccidua, emptying
directly into the placental lacunae, where the blood bathes the
placental villi projecting into them. The uterine body may be
regarded from one point of view as a huge venous plexus. The
walls of the veins are reduced to the intima, and running between

1 82

PREGNANCY.

muscle -bundles, the contraction of the uterine muscle after labor
obliterates them.

The nerves are increased more by a development of the con-
nective tissue about them (neurilemma) than by an increase of
the nerve -elements ; but there is some new development of nerve-
tissue, the filaments extending toward the uterine cavity. The
main supply of the womb is from the sympathetic system. The
ganglia in the genital region show hypertrophy, especially the
cervical.

Tlu lymphalics are increased by hypertrophy and by hyper-
plasia. The lymph-spaces below the uterine mucous membrane

are enormously enlarged, and the lymph-tubes leading from them
through the uterine muscles reach the size of a goose-quill.
These lymph-tubes or vessels arc collected in a plexus beneath
the peritoneum.

This arrangement and development of the lymphatics explain
in part the remarkably rapid absorption of a great portion of the
uterus after labor, and account for the ready absorption of in-
fectious material : with peritonitis oftentimes as an early symp-
omunication between the submucous and,
■oaces.
t Full Term — Tiie muscle-fibers of
; a very irregular arrangement. In

THE PHYSWI.OCy OF PREGNANCY. 183

the pregnant womb late in gestation three layers may be distin-
guished : An outer, a middle, and an internal layer. The outer is
continuous with the muscular fibers in the round ligaments and
tubes, and is mainly longitudinal in arrangement. The middle

which pass from their peritoneal

layer is composed of bundl
attachment obliquely downward
and inward to be attached to tlie
submucous tissue. Above the
"contraction ring," or "ring of
Handl," — the upper boundary of
the lower uterine segment, — the
oblique arrangement is less
marked, while below it is more
pronounced. The internal layer
is thin and poorly developed, ex-
cept around the orifices of the
womb. Its arrangement is chiefly
circular, and it is most strongly
devehiped at the openings of the
tubes and at the internal os.

Changes In Volume, Capacity,
and Weight, — Hefore impregna-
tion the length of the uterine
cavity is about 6.3 cm. {2 J^ in.);
at term it is increased to 30. 5 cm.
(12 in.), while its breadth is 22.9
cm. (9 in.) and its depth 20.32 cm.
(8 in.). The capacity changes
from little more than 16.5 c.c. (1
cu. in.) to more than 6600 c.c.
(400 cu. in.), and its weight in-
creases from about 2S.35 gni. ( [
ounce) to IJie neighborhood of
907.2 gm. (2 pounds).

Changes In Porm, Position, Di-
rection, and Toposraphlcal Rela-
tions.— At first the uterus is
changed from a llattened, pyri-
form body to a spherical or fig-
shape, and after the fourth month
to an ovoid. During the early
months the uterus descends into the pelvic cavity, as a result
of its increased weight. After the third month it rises steadily
until the fundus reaches the epigastrium in the ninth month, but
before term (four weeks in primipar^, ten days or one week

m\\\

I h^

■ ^

^^ £j(/™/„

v.^,J

FiK. 114.-

section of the will of

Ihe [ircgnant ule

U.S- The difference

in fexlurc belwe

en cervii and lower

cctiniing (0 Hofmciet,

is dearly show

as well as the loose-

meshed ami c

oBe-meahcd muscle-

layers of tlie upper and lower uleriiie

segmenls (llorm

icr).

l84 PKEGNANCV.

multipara;) the fundus sinks again, as the presenting part and lower
uterine segment become engaged in the pelvic cavity. This phe-
nomenon is explained by contraction of the overstretched ab-
dominal walls and a consequent diminution in the area of intra-
abdominal space, the uterus and its contents being displaced in
the direction of least resistance, namely, downward through the
superior strait, into the pelvic cavity. During the first three
months the womb exhibits a sharp anteflexion, due to the in-
creased weight of the body and the decreased tonicity of the
lower uterine segment.

Fig. lil

After the third month, as the womb rises into the abdominal
cavity, the laxity of the abdominal wall allows it to fall some-
what fonvard, so that the anteflexion persists to a certain degree,
but diminishes as the womb increases in length. In consequence
of the position of the sigmoid flexure and rectum, almost always
distended in constipated women, the uterus is tilted to the right
side and is rotated on its longitudinal axis, so that the anterior
surface looks toward the right, and the left broad ligament, with
its attached structures, becomes more accessible to abdominal pal-

THE PHYSIOLOGY OF PREGNANCY.

pation. The topographical relation of the intestines is impor-
tant. They should always be situated above and behind the
uterus, thus giving no resonance over the anterior abdominal wall
on percussion ; but in rare cases of excessive tympany the

intestines prolapse in front of the womb, giving a resonant
note on percussion all over the abdomen. A woman in my
service in the Philadelphia Hospital was told on this account
by the resident physi-
cian that she was not
pregnant, but she gave
birth to a full-term child
a few days later.

Alterations In the Cer-
vix.— The cer\'ix is soft-
ened and somewhat hy-
pertrophied during thi;
first four months, but
its canal is undilatcd
until the first stage of
labor begins. Through-
out the whole duration
of pregnancy the canal
remains unaltered in
length. The mucous glands of the cervix secrete a peculiarly

CHANGES IN THE SEVERAL SYSTEMS OF THE BODY. 1 8/

showed that the supposed enlargement of cardiac dullness on
percussion was due to displacement of the heart, and Lohlein
was unable to find an increase in the weight of the heart in a
number of specimens. ^ In consequence, it is claimed, of unusual
determination of blood to the brain there are developed, in about
one-half of the cases of pregnancy, on the inner table of the skull,
new formations of bone, called by Rokitansky osteophytes. It
has been claimed that the pulse of a pregnant woman does not
undergo the usual acceleration when the patient changes from a
horizontal to an erect posture (Jorisenne's sign of pregnancy).
This symptom, however, is of no value. The heart of the preg-
nant woman shares in the nervous irritability of the whole organ-
ism, and she is liable to ** cardiac nerve-storms."

The urine in pregnancy is increased in quantity, becomes
more watery, has a specific gravity of about 1014 ; but the quan-
tity of urea excreted is normal. The ** kyesteinic pellicle,"
which develops on the urine of pregnant women when allowed to
stand for a while, is no longer regarded as of diagnostic value.

The digestive tract is almost constantly disturbed in preg-
nancy. Nausea and vomiting, beginning at about the sixth
week and lasting to the third month, are so common as to be
diagnostic signs of great value. These manifestations are usually
worse on first arising from bed in the morning (morning sickness),
and are to be explained by a reflex irritation of the sympathetic
nervous system by the expansion of the uterus. The assumption
of the erect position suddenly increases the congestion of the
uterus and aggravates its irritability. Torpor of the intestines
and of the rectum, induced by pressure of the growing womb on
the abdominal contents, is the cause ordinarily of obstinate con-
stipation. If woman may be defined as a ** constipated biped,"
the pregnant woman is "a more constipated biped," and the
puerperal woman, for reasons hereafter to be described, '^amost
constipated biped."

The nervous system shows remarkable changes in conse-
quence of pregnancy. The.se are alterations in disposition,
perversions of taste (longings), a disposition to melancholia,
and possibly severe neuralgias, especially of the face and teeth.

Chang^es in weight must be expected in consequence of
seven pounds of baby, one pound of liquor amnii, a pound of pla-
centa, and two pounds of uterus which are to be found in a preg-
nant woman at term, not to mention the increased deposition of
fat all over the body and the additional quantity of blood formed
in pregnancy. An increase of -^ part of the original body-

» " MUlIer's Handbuch," vol. i.

1 88 PREGNANCY,

weight may be expected on the average, according to Gassner.
This estimate, however, is not uniformly correct, as exceptions
are frequently observed. In a series of cases which I investi-
gated in the Maternity Hospital there was an extreme variation of
from one to forty pounds in the gain of weight in pregnant women.

The chang^es in the respiratory apparatus are not of
great importance. The lungs are shorter but broader, leaving
the capacity little altered. Examination of the expired air has
shown an increased activity of the lungs in the excretion of the
products of life processes, the lungs sharing the work of the other
excrementory organs in disposing of the surplus effete products
from mother and fetus.

Prolong^ation of Pregnancy and Missed Labor. — Pregnancy
is quite frequently prolonged beyond 280 days. I have many
times seen a pregnancy last 3 10 days.^ It may have a duration
of 320 days, or 40 days above the average ; and there are cases
on record, though somewhat apocryphal, of even longer duration.
In about six per cent, of pregnant women the duration of preg-
nancy is over 300 days. The result in labor may be most
serious in consequence of overgrowth of the fetus. Some of the
worst cases of obstructed labor I have ever seen were due to
this cause. It is a rule of my practice, therefore, never to allow
any woman to go more than two weeks beyond term.

Missed labor means the occurrence of a few labor-pains at
term, their subsidence, and the retention of the product of con-
ception /;/ utcroiox a v^arying period thereafter. " Missed labor**
usually turns out to be extra-uterine pregnancy or pregnancy in
one horn of a uterus bicornis ; it may be due, however, to
obstructed cervix from cancer, conglutination, a tumor, or exces-
sive rigidity.

The Management of Normal Pregnancy. — Too frequently
the physician gives his pregnant patients no attention, assuming
that their condition is a physiological one and that they may be
regarded as individuals in good health till they fall in labor and
summon the physician to attend them. No view could be more
erroneous. The border-line between healtli and disease is so
easily passed in pregnancy that the most serious complications
may acquire irresistible headway, undetected, unless the patient
is advised c; ^'illy and constantly watched during the whole of
her gestatio '')nstipation must be corrected. The urine

should be . )ncc in two weeks during the whole dura-

tion of pre^ ncy til the last month, when the examinations

^ A very extensive l)il)li(»Ljraj)liy of j)r(:>lon^c-(l ]ir({i;nancy may be found in the
volumes of the '* Jalireshericlit ul)cr d. lortschi. a. d. (lebiet. d. (iyn. u.

»»

THE DIAGNOSIS OF PREGNANCY. 1 89

should be made once a week. The patient should be cautioned
to reduce her physical exercise below what she is ordinarily
accustomed to, and always to stop short of fatigue, avoiding par-
ticularly any sudden jolt or jar or any of the movements that
strain the abdomen and increase intra-abdominal pressure, such
as lifting a weight down from a height (a closet-shelf) or lifting
up a heavy weight.

The diet must be regulated so that the kidneys shall not be
overtaxed. Meat should be eaten but once a day, and a raven-
ous appetite, which sometimes appears in pregnancy, must not
be fully gratified. I have seen a pregnant woman's kidneys
break down in consequence of a Thanksgiving dinner. The
child's life was destroyed and the woman made a very nar-
row escape, eclampsia being averted only by vigorous treat-
ment An excessive amount of food in pregnancy has another
disadvantage. I delivered, in consultation, a primipara, with the
utmost difficulty, of a child weighing 1 1 3^ pounds. Her phy-
sician had advised her to drink two quarts of milk a day
between meals throughout pregnancy. She was easily delivered
a second time of a child weighing 7 ^ pounds after a regulated
diet in pregnancy.

The patient must be cautioned against exposure to cold and
wet ; one such exposure or sitting in a draft after being
overheated has frequently determined an acute nephritis, with
fatal results to both mother and child. Tonic remedies are some-
times called for if the hydremia of pregnancy is exaggerated or
if there is not a normal gain in weight. The syrup of the lacto-
phosphate of lime is administered with advantage to stay the
ravages in the teeth of pregnant women, and strychnin irl the
later months is claimed to influence labor beneficially and to
favor puerperal involution. The nipples should be prepared for
their future function by application of glycerol of tannin and
water, equal parts, twice a day for four weeks preceding confine-
ment.

THE DIAGNOSIS OF PREGNANCY.

It might seem to the inexperienced that the recognition of
pregnancy is an easy matter. Every physician has ample op-
portunity to familiarize himself with its signs, and these signs are
gross and easily appreciable, at least in the lat*^ nonths. But in
reality there is scarcely a common conditio . iman body

that is so often overlooked or mistaken fc ome' ng else, and
there are no mistakes in diagnosis so detrimental to a physici n's
reputation, or sometimes so fatal to the patient, as mistakes in the

190 PREGNANCY,

diagnosis of pregnancy. To cite as illustrations only cases of
which the author has personal knowledge : A physician per-
formed what he believed would be a Cesarean section on a
rachitic dwarf, thought to be in labor at term. Several other
physicians examined the patient before the operation, and all
agreed that she was pregnant and in labor. There was nothing
in her abdomen but the usual contents and a huge mass of
omental fat. It was a case of pseudocyesis.

A gynecologist on the staff of a large hospital has twice
operated for fibroid tumors of the womb, and only after the am-
putation of the uterus found that it was pregnant, and not the
seat of a fibroid tumor at all. Both patients died.

An obstetrician on the staff of another hospital attempted to
induce labor on a patient in the last stages of phthisis who evi-
dently would not live till term. The bougie, howfever, could
not be inserted more than 2]/^ inches. On the following day the
patient died. In anticipation of her death, all the arrangements
had been made for a postmortem Cesarean section the moment
she expired. The operation was performed before a large audi-
ence. The abdominal tumor proved to be an ovarian cyst, and
not a pregnant uterus. A woman was admitted to the medical
wards of a hospital with what was thought to be a cancer of
the stomach. Gastric lavage was energetically carried out with
unlooked-for success ; in several weeks all gastric symptoms
ceased. At the same time an abdominal tumor was observed,
which, on examination, proved to be a pregnant uterus. The
patient had been suffering from the vomiting of pregnancy. A
young unmarried girl of good family was about to be operated
upon for a splenic tumor wlien it was discovered that the tumor
was a pregnant womb much displaced and distorted by tight
lacing. A woman was sent to the author from a distant State for
operation on account of a large fibroid tumor of the uterus ; she
was pregnant with twins, had no fibroid, and was easily deliv-
ered. A young girl was referred to the author for the removal
of an ovarian cyst ; her physician stated that the eminent re-
spectability of the girl precluded the idea of pregnancy. Re-
spectability had proved no bar to the penetration of a sperma-
tozoon. She was pregnant at term.

The author on one occasion examined in consultation a
woman who was supposed to be pregnant twelve months. Her
physician and nurse had been engaged and every other prepara-
tion was made for the expected childbirth. The husband was
obliged meanwhile to sell his house, but a clause was inserted in
the deed that possession was not to be given the new owner till
the vendor's wife should be delivered. An examination showed

THE DIAGNOSIS OF PREGNANCY, I9I

the womb to be unimp^regnated. There had been very scanty
but regular menstruation, marked enlargement of the abdomen
due to omental and abdominal fat, and many of the subjective
signs of pregnancy. It was a typical case of pseudocyesis.
Instances of mistakes in the diagnosis of pregnancy could be
multiplied to a tedious length from the author's own experience ;
but the cases cited should be suflficient to demonstrate the liability
to error. If a physician would avoid such mistakes, he should
cultivate the habit of making a routine, methodical, careful ex-
amination of every patient who may be pregnant, neglecting none
of the important subjective and objective signs, and looking for
them in a regular order, which will preclude negligence or
omission.

The signs of pregnancy, in accordance with the laws of
symptomatology in general, are divided into the subjective and
the objective signs ; the former being the symptoms experienced
hy the patient herself, and the latter presenting themselves to
the senses of the examining physician.

Subjective Sis:ns. — ^Arranged as far as possible in the order
of their relative importance, they are :

Cessation of Menstruation. — This is the most valuable of the
subjective signs. It is always inquired for by the physician, and
is usually first mentioned by the patient if she is acting in good
faith ; but it is by no means a sure indication of pregnancy, and it
is not available if a woman conceives during the amenorrhea of
lactation, before menstruation is established, or after the meno-
pause. Amenorrhea may depend upon many other conditions,
such as change of climate, mental and nervous disorders, peri-
uterine inflammations, the growth of pelvic and abdominal
tumors, acquired atresia of the cervix, anemia, chlorosis, and
phthisis. The fear of impregnation in the unmarried, the ex-
pectation of it in newly married women, the intense longing for
maternity in some sterile women, and a beh'ef in the existence
of pregnancy in some cases of pseudocyesis are mental states
that have been known to suspend the function. On the con-
trary, menstruation, or a more or less periodical bloody discharge,
persists during the first three months of pregnancy in a very
small minority of cases. Rarely the flow may recur regularly,
though scantily, throughout the first half of gestation. There
may, therefore, be cessation of menstruation without pregnancy,
or persistence of menstruation in pregnancy. The patient's
statements, moreover, are not always to be depended upon.
She may deny the cessation of menstruation ; she may even stain
her napkins regularly with the blood of animals to deceive her

19^ PRECXAXCY.

famCy ; * or. in cases of spurious pregnane^*, she may assert that
the ilow has stopped, when in realit}* it persists, although some-
tmcii s.-^ scantilv as scarce! v to attract her attention.

Naaseft mtA. Voaritiai:. — This s}inptom depends upon the dis-
tention oi the gra\-id uterus in the beginning of pregnancy, and
us'jally first manifests itself at the sixth or seventh week. It ap-
pears so constantly and to such a marked degree in many patients
as to be recorded bv them as a certain indication of their condi-
tion, and in such cases considerable value may be attached to the
;\atier.t's sLitLment by the examining physician. I have had
jvat:cnts in whom nausea and vomiting apf>cared within the week
follouini; a fruitful coitus, though they did not suspect that they
were prci^^.ant.- Hut any irritation of the pelvic organs may
pr.xiuce the same result, as displacement or inflammation of the
uterus. coni:estion or inflammation of the tubes and ovaries, and
t'ne ^nvAtri y^\ pelvic tumors. The stomach itself may be dis-
i^niercv! ap.<i the \omitinij mav not be reflex. On the other
b.an*.:. this svniptoni is entirely absent in a considerable proportion
of •.•rc^!\int women. Si^me degree of salivation is usually asso-
ciatvAi witii ti'.c nausea and vomiting of pregnancy. In rare cases
the pt\\i!;>:n is ti.c predi>minant phenomenon.

Clumg:es in the Size and Shape of the Abdomen. — It has been
asserts r.i \\\.x\ at rirst there is a hx-pogastric flattening, due to the
sinking of t:.e uteres during the first few weeks of pregnancy
op. accoiiiu of ::> increased weight, but I have never found a
woman wi^.o !^^:iced this change in her shape. ^ The descent of
the womb, h.owcvcr, is associated with irritability of the bladder,
and kA tliis >\ niptoni the patient often complains. Later, the
ahdoir.cn i> >:caci!\- and proi^ressively enlarged until the last
mo!itii, wiicn tiic subsidence of the uterus diminishes the dis-
tentivMi of tiic abdomen, and at the same time g^ves rise to
symptoms ^A pressure o\\ the other pelvic organs and on the
blood-vessels and nerves kA the pelvis and lower extremities.

Tliere are man\- otlier causes, however, for abdominal en-
lari;ement besides prei^nancN'. as a deposition of fat in the omen-

> I was callcii to empty the uterus of a young girl, eighteen 3rears of age,
Mifteriiii: fnMii an incomj^lcie aix^rtion criminally induced. To this day her familv
haii no su>picion of what really occurreil. The girl had put her napkins in the
wa>h at the |H*riixls when she >hould have menstruated, stained with beef 's blood
obtained, from an ahaltoir.

2 A ijentleman asked me i<» attend his wife in confinement, between eight and
nine months later. When a-ked how he could su>|>ecl |>re«;nancy so early, he replied

that after breakfast that morning he had l)een seized with nausea and vomiting, an

infallible sign on several previous occasions that his wife had become pregnant.

* The French have a proverb : " En ventre plat

Enfant il y'a."

THE DIAGNOSIS OF PREGNANCY. 1 93

turn and abdominal walls, accumulation of fluid within the
abdominal cavity, and the various abdominal and pelvic tumors.
On the other hand, the enlargement of the abdomen due to
advanced pregnancy may actually escape the observation of the
patient herself, ^ or may be so well concealed by tight lacing as
to be almost imperceptible.

Changes Due to Increased Blood-supply to the Genitalia and
Breasts. — Owing to the congestion of the parts there is a tingling
sensation and a feeling of fullness in the breasts, with the
appearance in them of colostrum. A sense of heat and con-
gestion may be experienced in the pelvic organs, and there is
very likely to be some leukorrhea. These symptoms are obvi-
ously of little value.

Quickening:. — This is the name given to the sensation experi-
enced by the mother as the result of fetal movements, which, as
a rule, become powerful enough to be appreciated by her midway
between the fourth and fifth month of gestation. They may be
felt as early as the third month or not until the last month of
pregnancy, and some women do not experience them at all or
overlook their presence. They are not felt, of course, when the
child is dead. The woman interested to conceal her condition
will deny the occurrence of fetal movements ; and other women,
deceived by the action of the intestines, may honestly believe
that they feel a child in utcro.

Alterations In the Nervous System. — ^The nervous system is
almost uniformly disordered in pregnancy. Characteristic nerv-
ous disturbances are described by the vast majority of pregnant
women. These are changes in disposition, mental peculiari-
ties, and perversions of tastes. There is very often also a
sense of dizziness, a disposition to faint, and actual syncope.
For example, a woman usually amiable in disposition becomes
irritable, sullen, or morose ; a phlegmatic, placid individual may
become unusually vivacious, and the strangest fancies for eating
unusual and disgusting articles may appear. In some women,
however, these nervous symptoms are entirely wanting, or so
slight as to escape their own observation. There are many
other causes besides for changes in a woman's nervous organiza-
tion, such as nervous strain and hysteria.

Objective Si^rns. — These symptoms are obviously of much
more importance and value. They present themselves to the
physician's senses of sight, touch, and hearing.

^ I have seen an intelligent married woman, the mother of several children,
between seven and eight months pregnant, unconscious of the abdominal enlarge-
ment and entirely ignorant of ber condition.

194

PRECiVAiVCY.

Si^s of Pregnancy Ascertained by Inspection. — The Woman's

Fart: — Splotches of irregular pigmentation, called chloasmata,
appear on the brow and checks, and there are often dark rings
under the eyes. Moreover, as a physician questions a patient
in rej;ard to her condition, lie may observe, perhaps, evidences of
truth or untruth in her countenance as she replies ; though the
pregnant woman determined to conceal her condition is often an
actress of consummate ability.

Bn-asts. — The mammary glands are enlarged and obviously
distended ; they stand out prominently from the chest, and
tortuous veins are seen plainly under the skin. As pregnancy
advances, striae may be observed in the skin of the breasts.
The nipples are more prominent than in the non-pregnant

condition. Around the nipples there is a deepening in the color of
the pigmentation areola, and a widening of the pigmented area by
the development of the so-called secondary areola of pregnancy
(Fig, 129). In the pigmented area may be observed the seba-
ceous glands named after Montgomery, although he was rot
the first to direct attention to them and misunderstood their
significance. They arc often as large as buckshot in the pregnant
woman, and project quite conspicuously from the surface of the
skin. They are frequently, however, entirely absent. If the
breast is seized at its base and compressed toward the nipple
between the outspread thumb and four fingers of one hand, a
drop or two of turbid fluid (colostrum) may be seen to collect
upon the surface of the nipple,

^1^

Figure t.— Breast of a iioii pregnant wumnn of (he lilondo type.

Figuret 2 and 4.— tirca.-its of pre^naat women ii( Ihe bruuel type.

Fi|^re i- — liieul of a pr^nimt woman, a blonde.

Patnled from nalure, shnwiiig ihe inegulor distriliulioii of Monlgomeiy'i gland!
•nil conipftnlivr liistrnlion ot llie veins in ihe pregnant and the non-pregnnnl miinnn
ufaen the liri'asiB are allowed to hang unsupported by the clnlbing fur a lew iiiinulcs.

THE DJAGNOSIS OF PREGNANCY.

'95

All these mammary symptoms, however, may be observed
independently of prognancy. and rarely may be absent altogether
in that condition. The mammary glands of some women dis-
play a marked physiological activity at each menstrual period,
even to profuse milk-secretion, and it is by no means rare to
obsenc all the mammary signs of pregnancy accompanying the
growth of a pelvic or abdominal tumor, especially one of the
womb itself. Moreover, the woman may be impregnated during
lactation, or some activity of the glands may persist long after a
previous labor. Under such circumstances the mammary signs
of pregnancy arc valueless.

The AMoiiiiii. — As pregnancy advances the abdomen be-
comes more and more prominent ; obviously containing a tumor
pyriform in shape, with the narrow end downward, situated in
the median line, and spreading with approximate equality to either
side. There are other abdominal tumors, however, which have

igS

FHEGXANCY.

.^ ^E^^i^^i^

Fig. lji>— A, -Six raonlhs pregnant: B, seven munlhs pregnp

THE DIAGNOSIS OF PREGNANCY.

199

the same shape as a pregnant womb, and the gravid uterus is
often anomalous in form. In twin pregnancies, in breech pre-
sentations, in transverse positions, in some deformities of the
fetus, in some varieties of contracted pelvis, and in the presence
of other tumors coincident with pregnancy, the pregnant uterus
is altered in shape. Displacements of the uterus may also give
it an unusual appearance in pregnancy.

The umbilicus at the si.vth month is level with the surface of
the abdomen, and, later, pouts. It is surrounded by a ring of pig-
mentation, which extends above as high as the fundus uteri, and
below along the linea alba, which in pregnancy becomes the linea
nigra (Figs. 143, 143)- By a disorder in the arrangement of the
fibers in the cutis there appear to be cracks in the akin of the ab-
domen, especially toward the flanks, over the surface of the iliac
bones, and down upon the outer aspects of the thighs. If the

PJiEGNAUCY.

pregnancy is far advanced, and if tlie fetus is alive, fetal movements
may be plainly seen. These are of two characters : there is a
heaving movement of Uie fetal back, and a sharp, sudden tap of
the fetal extremities. Fetal movements, if unmistakable, are
positive signs of pregnancy, but they have been simulated by
twitching of the abdominal muscles and by the verraifonn
movements of the intestines.

Vagina and Vuh'a. — The mucous membrane of the vestibule
and of the vagina assumes a purple hue in the later months of
gestation, which has been aptly compared in color to the lees
of wine. The discoloration of the mucous membrane of the
vagina and of the vaginal introitus is usually most marked upon
the inner surface of the labia maj'ora and upon the fold of vagi-
nal mucous membrane on the anterior wall that comes into view
when the labia are separated (Plate 6,
Fig.s. 3 and 4). It is occa.sionally
confined to the fossa navicularis
(I'latc 6, Fig. 2), or to the deeper
portions of the vagina] rug<e. The
pigmentation of the mucous mem-
brane begins in some cases as early
as the fourth week, Chadwick ' in
281 cases found it diagnostic in thir-
teen per cent, at the end of the second
month ; in forty-six per cent, at the
end of the third month. The sign is by
no means an infallible one. It is often
absent altogether in early pregnancy,
and I have frequently noted its entire
absence at term. There are, more-
over, other conditions than pregnancy
which can give rise to it : erethism, pelvic tumors, intense con-
gestion of the pelvis. Even if the blue discoloration is not
visible, one may always notice in the later months a transforma-
tion of the pink color of the mucous membrane of the introitus
into a bright scarlet.

Signs Appreciated by the Sense of Touch. — Abdominal Palpa-
tion.— By this method arc learned the size and shape of the
uterus, and after the si.xth month the fetal back, head, and ex-
tremities may be felt.^ By placing the outstretched hand over
the fundus, the intermittent uterine contractions, to which atten-

I "Tr. Am, Gyn. Soc,," vnl, ii, 1886, p. 399. See «lso Farlow, "The
Ik»(Dn Med. and Surg, Jour.," vol. cxvii. No, 3, 1887.

' I'Dr 9. more eiteiided tlcKripiion of abi1aiDin>l palpation sec " Mechanism of

only below the umbilicus.

THE DIAGNOSIS OF PREGNANCY, 201

tion was first called by Braxton-Hicks, are perceived. At inter-
vals of about ten minutes throughout gestation the whole uterine
muscle contracts as it does in a labor-pain, the uterus hardening
under the hand so that its contents can no longer be easily ap-
preciated. This sign is available at the end of the third month,
and although it may be produced by any tumor distending the
uterine walls, as a collection of blood, an intra-uterine polyp, or a
soft myoma, it is almost a positive sign. It may, however, occur
sympathetically in extra-uterine pregnancy, and it is said that the
contractions of an overdistended bladder may be mistaken for
the rhythmical contractions of the gravid womb. Finally, fetal
movements may be felt as pregnancy advances. The sensation
conveyed to the hand is usually that of a finger-tap under a
blanket. The other fetal movement, however, — a heaving action
of the back, — is equally characteristic. This symptom is natur-
ally a positive sign of gestation. Fetal movements may be ex-
cited by placing a cold hand suddenly upon the woman's abdo-
men, or by pushing the fetus about in the womb.

Cofnbincd ExaminatioN. — The cervix in pregnancy is notably
softened as a result of the increased blood-supply and an edema
of the part. Goodell is the author of the ready rule of practice,
that when the cervix is as hard as one's nose pregnancy does
not exist, but when it is as soft as one's lips pregnancy is likely.

Rapidly growing myomata, however, acute metritis, and
hematometra can produce as soft a cervix as is felt in pregnancy,
and should the neck of the pregnant womb be the seat of an old ^
injury, with dense and extensive cicatrices, or should the cervix
be cancerous or syphilitic, there may be no appreciable soften-
ing in pregnancy.

Hegar's sign of early pregnancy depends upon a marked
softening of the lower uterine segment, by which it appears on
combined examination that the body and the cervix are discon-
nected, though on closer examination, the outer edges of the
lower uterine segment appearing a little firmer than the inter-
mediate portions, it seems that the cervix is joined to the body
of the womb by two indistinctly appreciable longitudinal bands.
The best method to elicit this symptom is to insert the forefinger
far into the rectum and the thumb into the vagina, while the
womb is pressed down by the other hand applied upon the
abdominal wall.

It is not always necessary, however, to make a rectal exami-
nation. By combined pressure, either through the anterior or
posterior vaginal walls and the abdominal wall above, the finger-
tips can be brought into relationship with the lower uterine
segment. Hegar's sign is by no means a certain one. It is not

a02 PREGNANCY.

invariably appreciable in pregnancy, and it might be felt in a non-
pregnant uterus, softened by congestion, inflammation, or the
presence in it of fluid.

Enlargement of the uterus, with a change in its shape and
consistency, is one of the most important symptoms in the early
weeks. The womb becomes more spherical in outline, softer in
consistency, and distinctly enlarged, while there is usually a
marked anteflexion in consequence of the weight of the body of
the uterus and of the softened lower uterine segment. By plac-
ing one hand over the fundus and the fingers of the other in the
vagina an impulse may be conveyed by the latter to the uterine
contents, which are displaced upward, communicating an impact

to the external hand and falling again into its original situation ;
a tap is felt upon the uterine and vaginal walls by the fingers
applied internally. To this symptom the name "ballottement "
has been given, and to the experienced examiner it is a positive
sign of the condition, though a small cystic tumor of the ovary
witli a long pedicle may simulate it closely, and the same symp-
tom might, of course, be elicited in an advanced extra-uterine
gestation.

Symptoms Ascertained by Auscultatron. — Mayor, a sui^con
of Geneva, was the first to discover, in i8i8, that the feta! heart-

THE DIAGNOSIS OF PREGNANCY, 203

sounds could be heard by applying the ear to the abdomen of a
pregnant woman when the child is alive. Three years later this
valuable symptom of pregnancy was described in an article by
Kergaradec presented to the French Academy. It is a symptom
available as early as the fifth month, although its value increases
with the advance of pregnancy. The fetal heart beats at the
rate of about 120 to 160 a minute, and the sound has aptly been
compared to the ticking of a watch under a pillow. The beat is
a double one, as in the adult heart. The area of the maximum
intensity of the fetal heart-sounds in anterior positions of the
vertex is about an inch below the umbilicus to the left or the
right of the median line, or in posterior positions of the vertex
in the flanks on a line passing through or somewhat below the
umbilicus. In breech presentations the maximum intensity is
usually above the umbilicus, and in transverse positions the
pulsations may be heard low upon the abdominal wall near the
symphysis. Occasionally they can best be heard over the fundus
uteri, the sound being transmitted by the fetal spine. Their
absence by no means excludes the existence of pregnancy. They
are not heard if the child is dead, if there is an abnormal
quantity of liquor amnii in the uterus, if the abdominal walls
are excessively thick, or in certain positions of the fetus. On
the other hand, the beat of the maternal aorta has often been
mistaken for the fetal heart, though this error is easily avoidable
if one feels the maternal pulse as he listens for the fetal heart-
sounds, and remembers that the aortic impulse is a single, the
fetal heart-beat a double, sound.

Another sign of pregnancy appealing to one's sense of
hearing is dullness on percussion down the median line of the
abdomen and for some distance on either side. It is possible,
however, in very rare cases of excessive tympanitic distention of
the intestines, to obtain a tympanitic note all over the anterior
wall of the abdomen, though the woman may be pregnant at
term. In such cases the distended intestines have surrounded
the womb and cover its anterior surface.

The uterine bruit, synchronous with the maternal heart-beat,
is often heard in pregnancy, but it may be heard also in large
uterine myomata and in ovarian cysts. It can usually best be
distinguished on the left lateral aspect of the pregnant womb,
as it is caused by some obstruction to the blood flowing through
the uterine artery. The funic souffle, present in about fifteen per
cent, of cases, if heard, is diagnostic of pregnancy. It is a high-
pitched, whistling, or hissing murmur, synchronous with the
fetal heart-beat. It is caused by some obstruction to the flow
of blood through the umbilical arteries.

204 PREGNANCY.

The fetal movements may be heard, in auscultation of the
abdomen,' as a dull thud against the abdominal walls. It was
while listening for the fetal movements that Mayor first heard
the fetal heart -sounds.

In auscultating the abdomen of a woman for the signs of
pregnancy, the examining physician should first use his ear
directly applied to the abdomen with nothing but a thin towel
intervening. A stethoscope should also be employed, however,
in doubtful cases and in situations where the ear can not be con-
veniently applied.

A positive diagnosis of pregnancy before the sixth week is
impossible, and the diagnosis may be only presumptive until
the fetal heart-sounds can be heard and fetal movements are felt

Clinically, the signs of pregnancy may be divided into those
of three trimesters, or periods of three months each. It is useless
for the practitioner to look for certain signs in one trimester only
available in the next. First trimester, — In this period the follow-
ing signs of pregnancy are available : Enlargement, change in
shape and bogginess of the uterine body, soft cervix, enlargement
and functional activity of the breasts, Hegar's sign, cessation of
menstruation, nausea, and vomiting. The second trimester will
exhibit, in addition to the above, enlargement of the abdomen,
intermittent contractions of the uterus, feeble fetal movements,
ballottement, fetal heart -sounds, and blue discoloration of the
vaginal mucous membrane. In the third trimester all the symp-
toms just enumerated become more easily appreciable. The
outlines of the fetal body arc distinguishable by abdominal palpa-
tion, and the presenting part may be felt through the roof of the
vaginal vault.

Estimation of the Duration of Pregnancy. — If the date of the
fruitful coitus can be ascertained, labor may be expected, on
the average, two hundred and seventy-one days ^ later. Ordi-
narily, the history of cessation of menstruation is depended upon
in making an estimate of the probable date of labor. Nagele ^
is the author of the convenient rule for predicting the date of the
expected confinement by counting back three months from the
first day of the last menstruation and adding seven days. For
seven months of the year this method is absolutely correct. In
April and September six days, in December and January five
days, and in PY'bruary four days should be added to obtain the
date of a period two hundred and eighty days after the first day

^ Discovered by Kergaradec in 1822.

2 Ahlfcld, "Monat. f. (iehurtsh," I'>d. xxxiv, p. 208, based on 425 cases.

3 " Lehrbuch der Geburtshuife."

THE DIAGNOSIS OF PREGNANCY, 205

of the last menstruation. It is to be noted, however, that the
prediction of the date of labor can never be more than approxi-
mately accurate, as the labor occurs only exceptionally two
hundred and eighty days from the first day of the last menstrual
period. ^ The variation of a few days either way is the rule, and
prolongation of pregnancy, even to a month or more, is by
no means excessively rare. Lowenhardt has proposed multi-
plying by ten the number of days between the last normal
menstruation and the one preceding, thus predicting, with a
greater accuracy than is otherwise possible, the probable dura-
tion of pregnancy. Thus, if the interval is twenty-six instead
of twenty-eight days, the pregnancy will last two hundred and
sixty days. Lusk says he has seen occasionally a curious con-
firmation of Lowenhardt's view, but my own experience would
not lead me to prefer this method to Nagcle's. If the patient is
not menstruating when she conceives, as in lactation, if the his-
tory of menstruation is not attainable, or is not to be depended
upon, an approximate idea of the date of pregnancy may be
gained by noting the height of the fundus. At the fourth
month it rises above the pelvic brim ; at the fifth it is midway
between the umbilicus and the symphysis ; at the sixth month
on a level with the umbilicus ; at the seventh month about four
fingers* breadth above the navel ; at the eighth month about
midway between the umbilicus and the xiphoid cartilage ; at the
ninth month the fundus reaches its highest level near the xiphoid
cartilage ; during the ninth month the fundus descends again
almost to the level at which it was at the eighth month, the pre-
senting part having entered the superior strait. The date of
quickening is of some value in estimating the duration of preg-
nancy. It may be expected in the twentieth week in primigrav-
idae, in the twenty-first and twenty -second weeks in niultigravidae.
But this symptom is exceptionally observed as early as the
fifteenth, thirteenth, or even the tenth w^ek, and some women do
not notice it till the seventh month.

Diaj^nosis of the Life or Death of the Fetus. — The fetal
heart-sounds are a most valuable sign of fetal life when they can
be heard. Positive knowledge on the part of the patient of fetal
movements is also of great value, and if the movements can be
felt, seen, or heard by the physician, there is, of course, positive
evidence of fetal life. All the signs of pregnancy without fetal
heart -sounds or fetal movements usually mean the presence of
a dead fetus'' /*;/ titcro. The most valuable sign of fetal death in

> Ahlfeld's statistics, based on 653 labors, show that pregnancy was ended in the
thirty-eighth week in 15.93 P^*" cent., in the thirty-ninth in 27.56 per cent., in the
fortieth in 26.19 per cent., and in the forty-first in 10 per cent, of the cases.

PREC.VA.VCY.

I
I

Fig. 146— I. Pholopaph of a pregnant woroHn inUcn three calendar monlhs
from the first day of Un mensiruaiion 1 I, 3, 4, same bdividuol ai louitb, fifth,
and siith lunai moiitha.

THE DIAGNOSIS OF PREGNANCY.

levenlh, eighth, ninth, uid tenth n

2o8 PREGNANCY,

pregnancy is the cessation of growth in the abdomen, which is
determined by successive weekly measurements of the abdomen
with a tape-measure, care being exercised to ascertain on each
occasion the maximum girth. If the fetus is alive, there is a
steady increase from week to week. If it is dead, there is no
increase in the abdominal measurements, and there may be a
decrease. For a more extended account of the diagnosis of
fetal life and death the student is referred to the section on the
diseases and death of the fetus.

It is obvious that a diagnosis of life or death of the fetus is
often of great importance, as a physician would be inclined to
induce labor to evacuate the womb of a dead fetal body if he
could be certain that the child had died ; and a knowledge of
fetal life or death would influence the treatment of nephritis or
of other complicating diseases of gestation. In case of doubt it
should be assumed that the fetus is still alive.

Diagnosis of tfie Sex of tfie Fetus. — It was thought for
some time that the diagnosis of fetal sex could be made by
listening to the rate of the fetal heart -beat, — a rate of 120 to
140 in the minute indicating the probability of a male fetus, while
a quicker heart-beat is indicative of a female child ; but observa-
tions conducted by Budin, also those in the Boston Lying-in
Hospital, and others made by the author, show that there is such
a variability in the fetal heart-rate from time to time that it is
impossible to predict by this means the sex of the fetus.

Diaj^nosis of a Prior Pregnancy. — The determination of
this point may be of medicolegal importance. A vaginal ex-
amination detects some degree of laceration of the cervix,
usually bilateral. The cervix is large and cylindrical. The
cervical canal is patulous, usually admitting the first joint of the
index finger. There arc old scars upon the skin of the ab-
domen, pointing to a former distention of the abdominal cavity,
and the abdominal walls are more flaccid than in a primigravida
or a nulliparous woman. The pelvic floor may be relaxed, and
there may possibly be tears of the levator ani muscles. The
hymen is not only torn, but is in great part destroyed, the rem-
nants forming the carunculai myrtiformcs. The vaginal mucous
membrane is smooth, and the vulva gapes so that by separation
of the labia majora often a great part of the vaginal canal can
be brought into view. There is often some degree of cystocele,
the anterior vaginal wall bulging downward and forward into the
vulvar orifice.

The breasts are ill supported and sag down, while upon the
skin, especially at the base of the glands, may be seen the white
and glistening scars of old strict.

THE DTACXOS/S OF PRECVAXCY.

209

Parturition in very rare cases, especially if the child is pre-
mature and small, may leave hardly a trace behind it, and the
delivery of a submucous fibroid may produce the same lacera-
tions of the cervix and pelvic floor that occur in childbirth.

Pseudocyesls, or Spurious Pregnancy. — In women who
ardently desire offspring, in those who fear impregnation, and in
individuals who, without longing for or dread of maternity, believe
themselves pregnant, the
subjective and some of the
objective signs of preg-
nancy may appear to so
striking a degree that the
patient herself is com-
pletely deceived, and not
infrequently her physician
shares her belief in the
existence of pregnancy. I
was once consulted by a
prostitute who firmly be-
lieved she had been preg-
nant for a yeai", or ever
since her occupation had
exposed her to the dan-
ger of impregnation. The
abdomen was distended ;
the breasts were enlarged
and painful, though not se-
creting : menstruation was
very scanty and irregular,
and the woman asserted
that she felt fetal move-
ments. The abdominal dis-
tention was due to fat and
gas. The uterus was un-
impregnated. I have fre-
quently seen women who
put on an excessive amount *'"' '^*'-
of abdominal and omental

fat as they approach middle age, and who, in consequence of
the abdominal enlargement, believe themselves pregnant. Men-
struation may be entirely absent or so scanty as scarcely to attract
the woman's attention, and all the subjective signs of pregnancy
may be accurately described. It often requires in these cases an
examination under anesthesia before the unimpregnated condition
of the uterus can be detected. Weir Mitchell asserts that once

2IO PREGNANCY.

these women's minds are disabused of the idea that they are preg-
nant, the abdominal enlargement rapidly subsides and all the sub-
jective symptoms of pregnancy immediately disappear. I have no
doubt of the accuracy of Dr. Mitchell's observation, but I can not
confirm his statement because the patient who is assured she is not
pregnant disappears from my view. Occasionally it is impossible
to convince a woman that she is not pregnant if she has allowed the
idea of pregnancy to take entire possession of her mind. There
applied for admission on one occasion, at the Maternity Hospital
of Philadelphia, a little, wizened old lady with gray hair, who
was apparently at least sixty years old. She volunteered the
statement that many years before she had subjected herself to
the dangers of illegitimate impregnation, and that ever since she
had been pregnant. Nothing could convince her of the truth,
and she indignantly left the hospital firmly possessed of her
monomaniacal idea. The case shown in figure 148 is one of the
most curious I have seen. The woman had an attack of pelvic
peritonitis just nine months before I first examined her. Her
menstruation had been absent ever since, but there had been a
vicarious flow regularly from her nose. The abdomen steadily
and rapidly enlarged, and the woman was firmly convinced that
she was pregnant. With this idpa she obtained admission to the
maternity wards of the Philadelphia Hospital, having been
previously examined by a physician who pronounced her
pregnant at term. The abdominal distention was due entirely
to tympanites, the result of partial obstruction of the sigmoid
flexure, w^hich was involved in the adhesions of the uterine ap-
pendages on the left side.

CHAPTER VU.
The Pathologfy of the Pregnant Woman*

DISEASES OF THE GENITALIA*

Displacements of the Pregnant Uterus. — The uterus in
pregnancy may be displaced forward, backward, to either side,
or downward. It may form part of the sac contents in inguinal
and ventral hernirt, and it may be twisted upon its pedicle, the
cervix.

Anteflexion of the Gravid Uterus. — Usually the growth of the
uterus upward into the abdominal cavit)' corrects the anteflexion
s|)ontancously, but if it is bound down by bands of adhesion
the result of pelvic inflammation, or the consequence of anterior

DISEASES OF THE GENITALIA. 211

fixation of the uterus by an abdominal or vaginal operation, pain
in the uterus and difficulty in urination result, until finally
the uterus expels its contents or forces its way up into the
abdominal cavity. Several cases have been observed lately in
which, after an anterior fixation of the uterus, the uterine cavity
enlarged solely by the distention of the posterior uterine wall,
the fundus and anterior wall much thickened, remaining at the
level of the pelvic brim.

Treatment. — Pelvic massage, tampons, and digital pressure
upward through the anterior vaginal vault may stretch or break
the adhesions and allow the uterus to ascend normally into the
abdominal cavity. Late in gestation the whole body of the
uterus may fall forward, producing a pendulous abdomen, in
consequence of greatly relaxed abdominal walls ; diminution in
the length of the abdominal cavity, as in kyphosis ; prevention
of the entrance into the pelvis of the presenting part, as in a
rachitic pelvis ; or by reason of an exaggerated separation of the
recti muscles. This variety of anterior displacement is best treated
by an abdominal binder, not tight enough to increase the intra-
abdominal pressure injuriously, but firm enough to afford support.

Retroflexion or Retroversion. — This displacement is of fre-
quent occurrence. It is explained almost invariably by the pre-
vious existence of a backward displacement, although an acute
backward displacement of the uterus may occur in the first few
months of pregnancy from the same causes that determine such
an accident at other times. A persistent retrodisplaccment of
the gravid uterus is more common in contracted than in normal
pelves, especially if the promontory is prominent, and the dis-
placement is more frequently a retroversion than a retroflexion.

Symptoms. — ^The earliest and most distinctive symptom is
dysuria, though there may have been backache, pelvic pain, and
a discharge of blood prior to the mechanical obstruction of the
neck of the bladder and the urethra. The presence of any of
these symptoms indicates an immediate vaginal examination,
whereupon the cervix is found just behind and perhaps above
the symphysis, and the body of the uterus distends Douglas's
pouch, and perhaps pushes the posterior vaginal wall forward
and downward to the vulvar orifice. In neglected cases, or if the
displacement is not spontaneously corrected, incarceration occurs.
By this term is meant the imprisonment of the growing uterus
in the pelvic cavity, where growth beyond a certain point is
impossible. The bladder and bowels are so compressed that
they may become gangrenous, and the pressure to which the
uterus is subjected leads to congestion, inflammation, and gan-
grene. The symptoms of this condition manifest themselves

212 PREGNANCY,

after the third month, often in the fifth, and sometimes as late
as the sixth month. They are : Occlusion of the bowel and
urethra, with their associated symptoms ; congestion, inflamma-
tion, and suppuration of the uterus, which may finally slough
with the development of peritonitis, septicemia, or pyemia.

Terminations of Retrodisplaceinents wlun Artificial Means
are Not Eynploycd to Correct the Displacement, — Spontaneous re-
position occurs in the majority of cases, though it should not be
awciited in practice. It is more likely in retroflexion than in retro-
version ;^ spontaneous abortion does not occur so frequently as
one would expect, on account of the mechanical difficulty of
emptying the uterus ; incarceration is the termination which the
physician must have in mind as always possible, and agciinst
which effective preventive treatment must always be adopted ;
expulsion of the uterus from the body as a whole through a rent
in the posterior vaginal wall is an effort on the part of nature to
correct an impossible condition of affairs, but it can obviously be
only partially successful. Rarely the disadvantages and dangers
of posterior displacement of the pregnant uterus are overcome
by "sacculation of the uterus." In this condition the fundus
and posterior wall of the uterus remain deep within the pelvis,
while the growing fetal body is accommodated by an enormous
distention of the anterior uterine wall.

Prognosis, — The outlook is always satisfactory as regards
maternal life if appropriate treatment is adopted early. If
the condition is overlooked or neglected, death frequently occurs.
In fifty-one fatal cases the following, in order of frequency, were
the causes of death : Uremia and exhaustion, rupture of the
bladder, septicemia, peritonitis from inflammation of the bladder,
pyemia, rupture of the peritoneum and of the vagina, errors in
treatment, and gangrene of the colon.

Treatment. — Tiic appropriate treatment is, of course, replace-
ment. If the attempt is made early, manipulation will succeed ;
the patient being placed in the lithotomy position, the fundus is
pressed upward by two fingers in the posterior vaginal vault in
the direction of one or the other sacro-iliac joints to avoid the
projecting promontory of the sacrum. Failing in this attempt,
the physician should next resort to the knee-chest posture and
to a repositor to press upon the fundus. It is always of advan-
tage in difficult cases to give an anesthetic.

If the knee-chest posture fails, and there is no obstruction
from an overfilled bladder, the ccr\'ix should next be drawn

— 5»h firm adhesions of long standinjj hindin^ the uterus firmly backward
laeotis reposition take place.

D/SliASES OF THE GEN!TAUA.

213

downward with a tenaculum, whilt: at the same time pressure is
made upward and to one side upon the fundus. If the attempts
at reposition succeed, as they always have in my hands, a large-
sized pessary or a tampon in the posterior vaginal vault should
be applied until the growth of the organ maintains it in the ab-
dominal cavity, and its increased size prevents its slipping back
under the promontorj'. The artificial support should be removed
midway between the third and fourth months. If the uterus is
bound down by strong inflammatory bands, steady and long-
continued pressure should be applied by means of large tampons
in the posterior vaginal
vault, inserted while the
padent is in the knee-
chest posture, by the aid
of a Sims' speculum, and
renewed daily. Failing
to secure reposition in
such a case by this plan
abortion should be in-
duced, before the symp-
toms of incarceration
appear.

Trcatmtnt of Rctro-
displacemint iduti the
Uterus is Incarcerated. —
The physician's attention
must first be directed
to the overfilled bladder.
Catheterization is usu-
ally easy if a prostatic
catheter is employed
and if the physician
recollects that the lower
segment of the bladder
as well as the urethra is
pressed upon, making of

the latter a canal perhaps more than five inches long (Fig. 149),
It might be of advantage, in case of difficulty in reaching
the accumulation of urine, to catch the cervix with a tenaculum
and to pull it backward, as suggested by Cohnstein, so as
to relieve the pressure upon the urethra. If catheterization is
impossible, suprapubic puncture of the bladder with an aspirating
needle is always practicable and perfectly safe if done in an aseptic
manner. After the bladder is emptied attempts at reposition
should be made as previously described. If these attempts

FIe- 149- — Froien
utFiuK of three nnd a half
from niplure of blaildcr.

214 PREGNANCY.

prove unavailing, abortion must be induced. If it is impossible
to effect an entrance into the cervix for this purpose, it is justifi-
able to puncture the uterine wall through the vaginal vault, and
thus draw off the liquor amnii. The organ may now respond
to efforts at replacement, or it may be possible to draw down the
cervix and to dilate its canal, to make feasible the evacuation of
the uterine contents. As a last resort, vaginal hysterectomy is
justifiable. It is, indeed, the operation of election '\{ the walls
of the uterus are badly inflamed, have begun to suppurate, or
are gangrenous.

Lateral Displacements. — These include late reposition, lattrro-
version, and lateroflexion. I^teroposition is usually a con-
genital defect, due to an abnormally short broad ligament,
placing the whole uterine body more to one side of the abdom-
inal cavitv than the other. Lateroflexion is also coneenital,
due to imperfect development of one side of the uterine body,
so that the imperfectly developed side acts like the string of a
bow and l^cnds the sound side on itself Lateroversion is a
tilting o{ the fundus to one side. Right lateroversion is the
rule during pregnancy. These malpositions of the uterus com-
plicate labor more than pregnancy (see Dystocia).

Prolapse of the Gravid Uterus. — The causes of this displace-
nunt arc : Impregnation in an organ already prolapsed,^ or
rctnncision. relaxed vaginal walls and outlet, and the increased
wcii^ht t>r the uterus '\\\ the first few weeks of pregnancy. Vio-
lent str.uiiing aiui traumatism, too, are possible causes.

///( sS'utiiucous tcrininations are : Complete spontaneous re-
position, wiiich is most frequent; incomplete reposition, the
lilt rus CiMUinuiiiL; in a state of partial prolapse to full term ; fail-
mi^ of i\ traction, iiulucing incarceration, with possible gancrrene
ol ll\r utvMus; Milurc of retraction, inducing abortion, which is
n\o>i \\Vk.A\ to occur, as there is no mechanical obstacle to the
esvMpc of tiic uterine contents. Pregnancy will not continue to
leun \\\ .1 conipletelx' prolapsed uterus.

.'..; w /;.'. — The appn^jiriate treatment of a prolapsed gravid
iilvujs i> reposition cuui the application of some variety of ball
(vsvuN. letamcd hy a firm T-bandage. If the uterus is incar-
veialevl. attempts at reposition should be cautiously made, but
\\ \W\ tail, v^wiui; to adhesions and edema, abortion should be
n\vluvxd auvl llje iM'i^an then replaced. If, however, the uterus
\x \i\testvvl, It shv>uKl be removed by a vaginal hysterectomy.

^ V )».UuMi \\\ uw wauls ot tho riiiladelphia Hospital had had a complete pro-
U.^N^v' ^^* ^^^^^ ^ v»pv»l,u>ou \\m\ »hh Hired by means of an enormously dilated cerrical
^^^^0 s\ui lU»^ wvMuau \\ak\ Wkw nupiv^naled in this manner. There was a sponU-
,^,^>s\% u\sv<»a^m vl llu' v\v«ml» Ih'Uuv iho lliird month of pregnancy.

DISEASES OF THE UTERINE MUSCLE. 21 5

The Presnant Uterus forming: a Part of a Hernial Protrusion. —

This displacement occurs very exceptionally in inguinal and ven-
tral, but never in crural, hernia, the uterus falling into the sac
before or after impregnation. The ventral variety is most frequent,
and may occur between abnormally separated recti muscles, or,
more rarely, is seen on the lateral aspect of the abdomen. When
it is associated very exceptionally with inguinal hernia, the preg-
nancy is apt to be in one horn of an abnormally developed uterus.

Treatment, — ^There should be an attempt at reposition. Fail-
ing in this, the cervix may be dilated and the hand inserted in
the uterus, to perform version and extraction. The emptied uterus
may then be returned to the abdominal cavity. The last resort
is Cesarean section or amputation of the pregnant uterus.
Winckel has reported such a case, with a successful issue.

Torsion. — A slight degree of torsion from left to right is
physiological and constant. A more exaggerated degree may
be due to some abnormal condition, usually inflammatory, near
the uterus, which results in twisting it upon its longitudinal axis.
An ovary may thus be brought in front and may be subjected
to traumatism during manipulation of the abdomen. Extreme
torsion of the pregnant uterus with lateral displacement has led
to a mistaken diagnosis of extra-uterine pregnancy.

DISEASES OF THE UTERINE MUSCLE.

Rheumatism of the myometrium is rare, but is occasion-
ally met with in women of rheumatic diathesis.

Syviptoms. — Great pain, localized in the uterine walls, lasting
throughout the latter months of pregnancy, and increased periodi-
cally by the intermittent uterine contractions. There may be a
subacute fever. The therapeutic test is the most valuable factor
in the diagnosis.

Treatment. — The administration of the salicylates is of imme-
diate effect.

Metritis is almost invariably acquired before impregnation.
The disease exercises a most deleterious influence upon gesta-
tion, giving rise to a sensation of weight and heaviness in the
pelvis, to an exaggeration of the reflex disturbances of pregnancy,
and often resulting in abortion.

Treatment, — Glycerin tampons may be packed in the vaginal
vault to support the womb and to deplete it, although the treat-
ment is very likely to induce abortion.

New growths complicate labor rather than gestation.
Fibromyomata grow rapidly on account of the increased

2l6 PREGNANCY.

blood-supply to the genitalia, and in exceptional cases some
operative interference is demanded for the pain and pressure
symptoms. On one occasion I was obliged to do a myomec-
tomy in pregnancy on account of excessive pain, and on another
to perform Cesarean section at seven and one-half months, be-
cause of the embarrassment of heart action and respiration due
to the enormous distention of the abdomen. Ovarian cysts, es-
pecially dermoids, may grow rapidly under the stimulus of
pregnancy, occasionally giving rise to such severe pain that extra-
uterine pregnancy is suspected. This was true of one of my
cases, in which I removed a dermoid cyst at the third month.
The pedicle may be twisted and the tumor become gangrenous.
It is more common, however, to witness an entire absence of
subjective symptoms till the onset of labor or during the puer-
perium. ^

Diseases of the Cervix. — The inflammatory diseases of the
cervix may exaggerate the reflex disturbances of pregnancy.
Endocervicitis and interstitial cervicitis are found in too many
cases of hypcremcsis to be a mere coincidence. An annoying
leukorrhca during pregnancy may have its origin in the cervical
canal. Exacerbations of the inflammation may give rise to bloody
discharges, especially at times corresponding to the menstrual
period. Supposed menstruation, persisting throughout preg-
nancy, has thus been accounted for.

TrcatDunt. — Applications of nitrate of silver solution, poured
into a cylindrical speculum, give the best results in endocervi-
citis. Congestion, inflammation, and hypertrophy of the cervix
are best treated by rest in bed and applications of glycerol of
tannin tampons.

Diseases of the vagina are due to an increased blood-sup-
ply or to infection.

Vaginal leulcorrhea is frequently an annoying complication of
pregnancy. A single application of a thirty per cent, solution
of carbolic acid in glycerin will relieve it more quickly than the
commonly eniploycci astringent and antiseptic douches. Another
successful plan of treatment is to pour into a cylindrical speculum
a twenty-grain solution of nitrate of silver to the ounce, then to
withdraw the speculum slowly so that the successive folds of
vaginal mucous membrane are bathed in it. Finally a douche
of weak salt solution should be administered.

1 17««P f Ke statistics of the child-bearing process, complicated hy pelvic and ab-
» Dystocia.

DISEASES OF THE VAGIXA. 217

Specific infection with the gonococcus should cause anxiety on
account of the eyes of the new-bom infant and the infection of the
mother after delivery, even should there be no great discomfort
during pregnancy. The condition requires energetic treatment.
A bichlorid douche, i : 2000, twice daily, and a tampon dusted
with tannic acid, give good results. For the bichlorid douche, a
permanganate of potassium solution, fsj : Oij (3.75 : 946 c.c), may
often be substituted with advantage. A study of vaginal secretions
during pregnancy (Doderlein) has thrown additional light on the
question of septic infection after labor. In the normal secretions,
especially of virgins, there is a large non-pathogenic bacillus,
which seems to have a destructive action upon other micro-
organisms by producing an intensely acid environment (prob-
ably due to lactic acid). In pathological secretions the reaction
is weakly acid, neutral, or alkaline ; there is also in pathological
secretions an increased amount of mucus, bubbles of gas, epithe-
lial cells, and a large number of mixed micro-organisms. Out
of 195 pregnant women examined by Doderlein, 44.6 per cent,
had pathological secretions.

Varices of the vagina may be dangerous if the veins are large
and their walls thin. The part should be guarded from trau-
matism, which might result in rupture of the distended veins
and an alarming if not a fatal hemorrhage.

Colpohypeiplasia cystica is a disease of the vaginal mucous
membrane, described by Winckel, in which little retention cysts
are scattered throughout the hypertrophicd mucous membrane.
In rare cases the fluid disappears from the cysts and its place is
taken by gas.

Polypoid fiypertrophies of the vaginal mucous membrane, usu-
ally at the site of the carunculae myrtiformcs, may attain con-
siderable size, causing discomfort during pregnancy, and possibly
obstructing the canal in labor. I have seen one case of such
enormous hypertrophy of the tissues surrounding the meatus
urinarius that the urethra completely filled the vaginal entrance
(Fig. 150).

Suburethral abscess is an accumulation of pus in the anterior
vaginal wall, bulging out at the vulvar orifice like a cystocele,
and on pressure discharging the pus slowly and imperfectly into
the urethra through the opening of Skene's glands. The abscess
should be opened through the vagina. ^

The diseases of the vulva are also largely due to an in-
creased blood-supply.

1 «* Archives de Tocol.," Oct., 1894.

218

FkEGNANCY.

VBrices in the labia majora may attain a large size. They
have been ruptured by muscular strain in an effort to prcser\e
the equilibrium, by sitting down violently upon a hard sub-
stance, or by a kick. The hemorrhage is always dangerous,
and has proved fatal.

Vegetations of the vulva may reacli excessive size in preg-
nancy. They are likely to give rise to an irritating, foul secre-
tion. It is sometimes possible to excise the growth. Excessive
hemorrhage, however, is to be feared, and the operation might
terminate pregnancy.

Pruritus vufvee may be a neurosis or may be due to irritating
vaginal discharges and to glycosuria. The disease is oftentimes
nin.st intractable to treatment. Antiseptic vaginal injections may

Fig. i5o.~H,-

iregnancy (author's case).

be tried, or a wash of two per cent, solution nitrate of silver
(Zweifel) ; menthol ointment, and other analgesic applications ;
very hot water, vinegar, and an infusion of tobacco are house-
hold remedies of some value. In the worst cases the woman
becomes almost maniacal. She may walk the floor alt night,
tearing at the vulva with her iinger -nails until the labia are raw
and her fingers are stained with blood. In such cases the induc-
tion of labor must be considered.

Edema of the vulva may be unilateral or bilateral, and in some
pregnant women reaches an extreme degree. It is due to pres-
sure upon the pelvic veins, to kidney insufficiency, or, in the uni-
lateral form, to labial abscess. There are some women who

D/SEASES OF THE rOXrA. 219

develop a vulvovaginal abscess regularly in every pregnancy,
and not at other times.

Trcatimnt. — If the cause can be removed, the edema disap-
pears. The treatment of kidney insufficiency rcnioveH the
dropsy of the labia associated with that condition, as it does
the other dropsies of the body. If tJie edema is due to pressure.

rest in bed, with the occasional assumption of the knee-chest
posture, often gives relief If the edema does not yield to gen-
eral treatment and to hot fomentations locally, the labia may be
punctured. It should be remembered, however, that even this
slight operation may terminate pregnancy. The vitality of the
part, moreover, is so lowered that infection and even gangrene
may follow the puncture. In the unilateral edema, associated

220 PKEO.VAjVCY.

with labial abscess, the vulvovaginal gland should be laid open
in the last month of pregnancy, curetted, cauterii-^d with car-
bolic acid, and packed with gauze. One of the worst cases of
puerperal sepsis I have ever seen was due to infection from a
vulvovaginal abscess that ruptured during labor.

Periuterine Inflammations and Adhesions. — Old cases of pelvic
adhesions maj' be benefited by massage and tampons. The most
satisfactory results, however, are secured by appropriate treat-
ment during the intervals between pregnancies. Fresh attacks of
periuterine inflammation in pregnancy, depending upon oopho-
ritis and pyosalpingitis, are exceedingly dangerous. Unlikely as
it may seem, a woman may be impregnated, though she have at

52.^ — Eiicma of vulvn in tlie eighlh monlh of pregnancy, due lo pressure,
pelvis. Felnl hem] iiiifagBgiMl Blnve ihe pelvic lirim. Swelling dis.ip-
]ieared in a few hours after molliple punctures (University Maternity).

conception a pyosalpinx and densely adherent tubes and ovaries.
The inflammation of the adnexa may be lighted up afresh by the
congestion of pregnancy. In such cases a septic peritonitis may
be averted only by a prompt abdominal section and the removal
of the appendages.

Loosening of and Pain tn the Pelvic Jointe. — If the normal
relaxation of the pelvic joints in pregnancy is carried to an ab-
normal degree, it may interfere with locomotion. The diagnosis
is made by a vaginal examination, the patient, in the erect
posture, taking a step or two. while the examiner holds his
index-finger in the vagina against the posterior surface of the
symphysis.

DISEASES OF THE ALIMENTARY CANAL. 221

Treatment, — Application of a firm binder about the hips will
usually make the patient comfortable. Rest in bed may be
necessary in exaggerated cases.

The pelvic joints, especially one sacro-iliac, may be the seat
of severe f)ain of rheumatic origin. The patient may be entirely
disabled by her suffering. This pain yields immediately to
antirheumatic remedies like the salicylate of cinchonidin, and to
no others.

Breasts. — Mammary Abscess. — Its cause, course, and treat-
ment are the same as when it occurs during the puerperium.

Eczema of the nipples may be very obstinate in its resistance
to treatment. Relief may only be secured after delivery. Mean-
while the usual treatment for eczema may be tried with more or
less success.

Mammary tumors may take on a very rapid growth under the
stimulus of pregnancy. I have seen a simple adenoma the size
of a walnut, for years before quiescent, reach the size of a cocoa-
nut during pregnancy.

DISEASES OF THE ALIMENTARY CANAL*

Mouth. — Caries of the teeth frequently troubles a pregnant
woman. It is a common saying that for every child a woman
will lose a tooth. As a rule, prolonged and painful dental opera-
tions are inadvisable during pregnancy. Temporary work only
should be done by the dentist, who should be acquainted with
his patient's condition. The syrup of the lactophosphate of lime,
fej (3-75 c.c.) t. i. d., should be prescribed for all pregnant women
who display a tendency to dental decay.

Qinsivitis. — In this disease the gums are spongy, inflamed,
bleed easily, and are possibly ulcerated. The condition may
obstinately resist treatment until pregnancy is concluded. Occa-
sionally the gingivitis extends to a stomatitis, and rarely lasts
through, and is aggravated by lactation, only disappearing when
the child is weaned. The inflammation may extend down the
esophagus to the stomach, producing dyspepsia and an obstinate
vomiting. Astringent and cleansing mouth -washes, containing
tincture of myrrh, give the best results in the treatment of this
affection.

Toothache may develop with or without pathological changes
in the mouth, and in the latter case may resist all treatment. It
usually subsides in the second half of gestation if it is a neurosis.
If it is due to dental caries, temporary dental treatment should
give relief.

222 PREGNANCY.

Ptyalism. — The cause is not known. It is a neurosis or a
reflex irritation of the sympathetic nervous system. Astringents,
belladonna, chloral, etc., may be employed. It disappears usu-
ally in the latter months, but may recur in each succeeding precr-
nancy. One of my patients had salivation in five successive
pregnancies. Every night a large receptacle was placed by the
bedside into which saliva was expectorated in astonishing quan-
tities.

The Stomach. — ^There is a physiological, an exaggerated,
and a pernicious vomiting in pregnancy. The last is a serious
disease, with a high mortality.

Pernicious vomiting: is such an exaggeration of the physio-
logical nausea and vomiting of pregnancy that the stomach
becomes almost or quite unretentive.

Causes. — The commonest cause is a reflex irritation of the
stomach from the distention of the uterus and an irritation of
the latter's sympathetic nerve-endings, due to the stretching of
the uterine walls. It is, therefore, more common in primigrav-
id^, especially in elderly women ; in twin pregnancies ; in hydram-
nios ; in chronic metritis or displacement of the uterus ; in cases
of chronically thickened, inelastic, or diseased cervices, and in a
hypcrcsthctic or disordered condition of the nervous system.
Another cause may be found in inflammation of the lining mucous
membrane of the cerv^ix or of the uterus. Engorgement or
inflammation of neighboring organs, as inflamed tubes or ovaries,
or an old or fresh appendicitis, increases the irritation of the
distending womb, usually by reason of adhesions which bind
it down. A patliolo<j^icaI condition of the stomach, as chronic
gastritis or i^astric ulcer, will naturally increase gastric irrita-
bility, so tliat the stomach feels acutely the reflex irritation of
pregnancy. There may rarely be some pathological condition
of the intestinal tract, as polypi or bands of adhesions as a
cause of pernicious vomiting. Immoderate indulgence in sexual
intercourse is a not infrequent cause. Kidney insufficiency should
always be suspected if tlie vomiting recurs late in pregnancy.

Diagnosis. — The recognition of the cause may be difficult,
but the diagnosis of the condition is easy. There is usually a
subnormal temix-Tature. but there may be fever ; there is great
emaciation, pallor, and loss of strength. The lips are dried and
cracked, the tongue is brown and coated, and the breath foul.
There is constant retching, and ever>^thing put into the stomach
is either immediately rejected or comes up undigested in a short
time. Whether anything is ingested or not, mucus and bile are
vomited from time to time. A gastric ulcer is not uncommonly
the result of the disordered secretion of the stomach and the

DISEASES OF THE ALIMENTARY CANAL. 223

reduced vitality of its walls. In such cases the vomiting becomes
bloody and the patient may succumb to repeated gastric hemor-
rhages, which she can not endure in her enfeebled condition.
The most unfortunate mistake in the diagnosis of the pernicious
vomiting of pregnancy is the failure to recognize the existence
of gestation and the consequent belief that the emesis is that
of hysteria, gastric ulcer, or cancer. Persistent vomiting in a
woman of child-bearing age should always arouse a suspicion of
pregnancy and should always indicate a vaginal examination.

The treatment of hyperemesis gravidarum should be directed
toward the cause if it is ascertainable or amenable to treatment.
The various remedial measures required in individual cases may
be conveniently studied under the following heads :

Hygienic. — This includes regulation of the diet, attention to
the gastro-intestinal tract, to the woman's sexual relations, and to
her mode of life. The physician should advise a light breakfast
of tea and toast or milk, taken in bed before getting up, the patient
lying flat upon her back. Resting quietly for a half-hour or so
after the ingestion of light, simple food, the distressing nausea
and vomiting usually felt on first rising in the morning may be
entirely avoided. Sexual intercourse should be forbidden. Oc-
casionally there is improvement when the sensation of swallowing
is removed by a cocain spray of the fauces, or by injecting food
into the stomach through an esophageal tube. Rectal alimen-
tation must be resorted to in the worst cases, the enemata
being non-irritating, so as not to provoke an exhausting diar-
rhea, partially digested, easily absorbed, and not administered in
too large amounts or too frequently. Four to six ounces may
be given three or four times a day, of liquid pcptonoids, pancrea-
tized milk, or peptonized beef-tea. The rectum should be washed
out twice a day, and after the irrigation a pint of normal salt
solution should be injected high up in the bowel for the relief
of the distressing thirst that is a constant symptom. A toler-
ance of the stomach may at times be secured by allowing appar-
ently unsuitable articles of food if they are strongly craved by
the patient. In all cases of true pernicious vomiting the patient
must be confined to bed, the room should be darkened and kept
absolutely quiet, and eve r)^ atom of the patient's strength should
be saved by careful nursing.

It can not be too emphatically stated that the vomiting of
pregnancy is a neurosis. Hence a strong nervous impression
upon the patient or the establishment of a moral control over
her, as in the treatment of hysteria, will often give brilliant re-
sults. I have cured many a ca.se of hyperemesis by making a
vaginal examination, and on several occasions my entrance into

224 PREGNANCY.

tlie patient's bedroom as a consultant immediately checked a
vomiting previously uncontrollable. Again, a positive statement
that a certain remedy would unfailingly check the vomiting has
made it immediately successful.

The Medicinal Treatment. — The drugs that have been lauded
as specifics in the treatment of hyperemesis include a large pro-
portion of those in the pharmacopeia. The remedies most
worthy of mention are: lodin, gtt. j-ij (0.06 to o. I3 cc) in
water ; oxalate of cerium, subnitrate of bismuth, tincture of nux
vomica, antipyrin, wine of ipecacuanha in small doses, menthol,
hydrobromate of hyoscin, and cocain. The nerve sedatives —
the bromids, chloral, and opium—are the most reliable (sodium
bromid, gr. x (0.65 gm.), in aq. camph., Jiv (15.50 gm.}, four
times a day, is a useful routine prescription). If the stomach is
intolerant of drugs, recourse maybe had to cnemata of sodium or
potassium bromid, gr. xl (2.60 gm.). and chloral, gr, xx (1.3 gm.),
two or three times a day, dissolved in several ounces of water.

Tlie Gynecological Treatment. — If the vomiting of pregnancy
becomes exaggerated and resists the ordinary hygienic and
medicinal treatment, a vaginal examination should be insisted
upon. Various abnormal conditions of the pelvic organs may
be discovered and must be treated, A displaced uterus must be
replaced. If the cervix is engorged, thickened, or cicatricial, or
if its canal is inflamed, applications may be made to it through a
cylindrical speculum, a twenty-grain solution of nitrate of silver,
for example, being poured into the speculum until the cervix is
submerged in it. Multiple punctures of the cervix or the use of
glycerin tampons may be considered, though these measures
would be employed at the risk of inducing abortion. Peroxid
of hydrogen has been found useful poured into the speculum as
just described. It is obvious that if applications to the cervical
canal are made with an applicator and cotton, abortion might
result. If there is metritis, with a large, heavy, inelastic womb,
treatment may not accomplish much during pregnancy. Glyc-
erin tampons may be tried if the knee-chest posture, rest in
bed, and free purgation fail, but they may induce abortion. An
adherent, displaced womb, with old or recent peri-uterine inflam-
mation, is not infrequently responsible for a particularly obstfttste. >
and violent form of emcsis. Pelvic massage and vagina! packing
must be resorted to at the risk of terminating pi-egnuncy.
strong solution of cocain. applied to the cervix and to the vaginal
vault, has proven beneficial in a few cases, "

cer\'ix with the fingers or with a boi
wonderfully succe.s.sful. This so-cal'
has many cnthu.sia.stic advocates,

DISEASES OF THE ALIMENTARY CANAL. 225

that it is unreliable. When it has succeeded it has been due, I
believe, to the nervous impression produced upon the patient.

The Obstetrical Treatment. — Induction of abortion or of pre-
mature labor should be regarded as the last resort, but yet it
should not be delayed too long. If a patient retains absolutely
nothing on her stomach and must be fed by the rectum ; if she
vomits incessandy whether anything is put into the stomach or
not ; if the pulse rises to 1 20 and the prostration is really alarm-
ing, abortion must be induced. As a rule, I do not continue
rectal alimentation more than a week. There is one case on
record in which rectal feeding was employed with success for
almost two months, but this single instance should not encourage
physicians to persist for an inordinate length of time in rectal
alimentation. There are many deaths recorded of women fairly
well nourished by food injected in the bowel, but fatally ex-
hausted by incessant retching and vomiting.

The mortality of the pernicious vomiting of pregnancy is
high. Of 239 cases, 95 died ; of 57 cases treated by the usual
means, 28 died ; of 36 ca.ses treated by the induction of abortion,
9 died. I have induced abortion for hyperemesis twelve times.
Two patients died. In one case 1 was called to see the woman
in consultadon when she was almost moribund. The induction
of abortion proved too great a shock to her, easy and simple as
the operation is. In the other case the religious scruples of the
family prevented the termination of the pregnancy when I first
advised it. Ten days later, the patient being obviously at death's
door, the operation was demanded.

The Intestines. — Constipation should be guarded against to
prevent overwork of the kidneys. The small compressed pill of
aloin, belladonna, cascara, and strjxhnin, kept in stock by all
pharmacists, is the best routine remedy. The weaker mineral
waters and pulv. glycyrrhiz-T comp. ma)' be used. Active purges
not only disturb the digestion, but may interrupt the course of
gestation.

Dlurbea. — When the ordinary astringent remedies fail to
check a diarrhea in pregnancy, nerve sedatives should be tried.
There is a nervous diarrhea of pregnancy due to the mechanical
' irritation of the intestines by the growing uterus.

Oastiic and Intestinal Indigestion. — The latter is not uncommon

in primigravida;. and may give rise to such severe abdominal pains

that a suspicion of extra-uterine pregnancy seems justified. These

^iglUQll^llilH^gim^^ leurosis, and may yield to valerian,

after the ordinary treatment for

' from a mild catarrhal con-

226 FKEGA'AXCy.

dition of the bile-ducts, which may have existed before pregnancj-.
This class of cases is of little clinical importance. It should be
remembered, however, that a serious condition may develop in
pregnane)' as the result of excessive work thrown upon the liver.
— namely, an acute degeneration of the whole hepatic structure.
Localized degenerations of the liver are seen in all fatal cases of
eclampsia, and the poisonous substances circulating in the blood
in that disease may act upon the liver like phosphorus, pro-
ducing acute yellow atrophy.

TreatwcnI. — The simple catarrhal jaundice is treated b>'
regulation of diet and of the bowels, and by the administration
of calomel to secure a free discharge of bile. The graver fonn
of hepatic degeneration is likely to be rapidly fatal.

Appendicitis In Pregnancy — Fifteen cases have been collected
by Abrahams' with .seven maternal deaths. Called on one occa-
sion to sec a woman with acute peritonitis in the fifth month of preg-
nancy, I found, after opening the abdomen, pools of pus lying be-
tween the coils of intestines, a gangrenous appendix, and two
perforation.* of the caput coli. The pregnant uterus wa.s turned out
of the abdominal cavity, the pus was carefully sponged out with
gauze ]>ad.s, the appendix was amputated, and the perforations in
the colon were closed by a sero.serous stitch. The uterus was
thun retiinicti to the abdominal cavity, and the wound was dosed
with gau/e draina[;e for eighteen hours. Not only did the woman
recn\cr. but prej;nancy continued undisturbed to term.

Hemorrhoids. — The pelvic congestion of pregnancy and the
mechanical interference with the circulation by the bulk of the
graviii uterus predispose to hemorrhoids, and aggrav.ite them
if tliey antedate concejition. Palliative treatment alone is per-
missible. \\\ ()iiitnient of etpial parts of ung. gall, and ung.
stramon. will be ft)und .serviceable. Cocain, lead .salts, and
opium may also bo useful. Rest in the horizontal posture, the
knee-chest po.sture .several times a day, and the routine use rf
laxatives may be nece.ssary. As in all cases of hemorrhoids, the
bidet ''ivcs {jreat cocnfort.

DISEASES OF THE URINARY APPARATUS^
Kidneys. — The Kidney of Pregrnancy. — There is a pathological

condition of the kidneys so frequently developed in pr^cnancj'
(fifty-eight out of seventy. Fischer-) that it deserves the name of
" kidney of pregnancy."

1 " Anier. Jour, Olj>letrics," Feb., 1897.
' " Prager med, Woeliens. ," 1892, No. 17.

DISEASES OF THE URINARY APPARATUS. 22/

Pathology, — There is anemia with fatty infiltration of the epi-
iheHal cells, without acute or chronic inflammation.

Etiology. — ^The causes of the common changes in the kidney
during pregnancy are still obscure. They have been attributed
to pressure on the renal blood-vessels, to the direct compression
of the kidneys by the gravid uterus, to a serous condition of the
blood in pregnancy, to the influence of the weather, to pressure
upon the ureters, and to spasmodic contraction of the renal arteries.
It is most likely that the condition is due to a diminution of
the blood-supply, most probably brought about by increased
intra-abdominal tension and by a contraction of the arterioles in
the kidneys, due to the irritation to which they are subjected
by the effete substances contained in superabundance in the
blood of pregnant women.

Symptoms. — There is often albuminuria in advanced degrees
of the condition. Hyaline and granular casts, with epithelium
filled with fat, may be found. The kidneys may prove physio-
logically insufficient, and there may appear all the symptoms of
renal insufficiency observed in true nephritis.

Frequency and Course. — About six per cent, of all pregnant
w^omen have albumin in the urine, though a vastly larger pro-
portion show some degree of the kidney of pregnancy, if there is
an opportunity for a postmortem examination. Albuminuria
occurs most frequently in primigravidae. The kidney disturbance
runs a subacute course, manifesting, itself most plainly in the
latter months of gestation. It may influence the general health,
the course of pregnancy, and the occurrence of eclampsia, just
as inflammatory' renal diseases would do. The renal insuflficiency
exerts a malign influence upon the fetus, also, especially in the
production of placental apoplexies. If the mother becomes
uremic, the fetus is also poisoned and rarely survives its birth
more than a few hours. The dangers to both mother and child
are greatest if the condition develops suddenly. The renal in-
sufficiency of the kidney of pregnancy disappears with the
cessation of gestation.

The treatment is practically the same as for true nephritis,
so that the management of the kidney complications of pregnancy
will be considered without reference to the cause of the kidney
insufficiency.

Acute and Chronic Nephritis. — These diseases may occur at
any time during pregnancy, with their usual symptoms. The
extra amount of work thrown upon the kidneys during pregnancy
makes the prognosis of kidney diseases graver than at other
periods of adult life, and a more energetic treatment may be
demanded in the pregnant than in the non-pregnant woman.

228

PREGNANCY,

Premature expulsion of the ovum and outbursts of eclampsia are
frequent. Chronic nephritis may be acquired before or during
pregnancy. Acute nephritis or a sudden insufficiency of the
kidneys may be the result of exposure to cold, wet feet, sitting
in a draft when overheated, or a single gratification of a ravenous
appetite.

Differential Diagnosis betzueen True Nephritis and the Kidney
of Pregnancy, — If the kidney disease existed before pregnancy,
well-marked symptoms will develop in the earlier months.
The appearance of the first symptoms after the sixth month
usually justifies the assumption that the disease has had its
origin during pregnancy, and is nothing more than the tempo-
rary disturbance of that condition. I have, however, seen
eclampsia break out in the last month of pregnancy or during
labor in a woman who had a history of violent headaches and
scanty urination for two years before conception, and in another
who had had scarlet fever during girlhood. In both these women
there was probably a latent nephritis, though there was not a
sign of it in pregnancy until the onset of the convulsions. The
following differential signs may aid one in the diagnosis of a
doubtful case :

Chronic Nephritis.

The history may point to its exi>jtence
before pregnancy.

Quantity of urine increased and its spe-
cific gravity low ; but these condi-
tions are normal in pregnancy.

Sudden diminution in quantity may
appear.

Occasional presence of albuminuric
retinitis.

The symptoms of kidney insufficiency
— albuminuria, edema, somnolence,
headache — apt to be pronounced in
the earlier months.

The autopsy shows inflammatory
changes, chronic or acute.

Persbts after delivery.

Casts appear early and in abundance.

KiDNKY OF Pregnancy.

The history would indicate that the
kidneys were normal before concep-
tion.

Quantity of urine likely to be increased
and its specific gravity is low.

Sudden diminution possible, as in true
nephritis.

Does not appear in the kidney of preg-
nancy, so far as my observation
goes.

Do not appear, as a rule, until after the
sixth month of gestation.

Anemia and fatty degeneration of the
kidney are found postmortem. No
inflammatory changes, though the
kidneys may become secondarily
congested if convulsions have oc-
curred.

Disappears after delivery.

Casts only in bad cases, not appearing
usually until the other s3nnptoms of
kidney insufficiency have developed.

*« always of paramount importance to know,

V. what the condition of the kidneys may

urine should be repeatedly examined,

DISEASES OF THE URINARY APPARATUS. 229

at least every two weeks during the eariier months and once
a week during the last month. If albumin appears, but if its
quantity is small, if there are no casts, no history of a previous
nephritis, and no symptoms of general systemic disturbance,
dietetic and hygienic management may be sufficient, so long as
the case is kept under careful observation. Meat should be
eaten but once every other day. Large drafts of water should
be systematically drunk. The greatest prudence must be exer-
cised about adequate underclothing, exposure to cold and wet
feet, and a laxative should be taken regularly, if it is required.
If the amount of urine voided is decidedly diminished, if casts
are discovered and edema appears, the patient should keep her
room or should be put to bed ; the bowels must be kept freely
open ; the diet should be reduced to milk and Basham's mixture,
or some other diuretic should be given. Three-grain doses of
cafTein have given good results. Benzoic acid is also satisfactory.
If an exclusive milk diet is impossible, milk soups, a small
amount of toast, the lighter vegetables, — squash, asparagus,
beets, salad, spinach, etc., — may be allowed in small quantities.
If under this plan of treatment the symptoms grow progres-
sively worse, the termination of pregnancy is necessary. There
is no disease of pregnancy with which the physician can so ill
afford to trifle as this.

Obscurity of vision or actual blindness, demonstrating usually
the presence of albuminuric retinitis, indicates the induction of
labor or of abortion without a moment's unnecessary delay.
Both ophthalmologists and obstetricians of experience are agreed
that if the woman's vision, nay, if her life, is to be saved, preg-
nancy must be terminated at once. It should be remembered
that if interference is long postponed, it may come too late.
After the uterus is emptied eclampsia may occur, if the woman's
system is allowed to become thoroughly saturated with the effete
products of life activity in both mother and fetus, which the
physiologically insufficient kidneys do not excrete. I am in the
habit of depending upon the quantity of albumin as a guide to
determining the question of inducing labor. In every case of
albuminuria in pregnancy I have daily examinations made with
an Esbach albuminometer. If, in spite of confinement to bed,
a milk diet, ingestion of large quantities of water, diuretics, and
hot baths every other day, the albumin steadily or suddenly
increases, I terminate pregnancy. A sudden diminution in the
quantity of urine, excessive edema, and somnolence would also
decide the question indubitably in favor of terminating gestation.
The quantity of urea excreted would always be of great interest
and value in deciding for or against the induction of labor, but

230 PREGNANCY,

unless the total amount of urine in the twenty-four hours is
measured, the exact estimation of the quantity of urea excreted
is impracticable.

Renal tumors are rare. They are to be diagnosticated and
treated according to the individual features of the case, but it
must be borne in mind that any disease or abnormality of the
kidney predisposes to insufficiency of excretion. The anatomi-
cally perfect kidney is likely, but not certain, to be physiologically
sufficient. The unhealthy kidney will probably, but not certainly,
be insufficient.

Dislocation of tiie Kidney. — The right kidney is almost always
the one affected. The displacement of the kidney is not infre-
quently associated with displacements of the gravid uterus.
Abortion may result if the floating kidney happens to become
twisted upon its pedicle. From the pressure to which the
displaced kidney is subjected, and in consequence of interference
with the renal circulation by torsion of the vessels, the kidney of
pregnancy may develop. A congenital fixation of the kidney in
the pelvis has been noted in the child-bearing woman. ^ It is
usually the left (fourteen out of fifteen cases (Cragin) ).

Diseases of tlie Pelvis of tlie Kidney. — Pyelitis has the history
of all the infectious diseases in pregnancy ; it is aggravated by the
condition, and reacts unfavorably upon it. Premature expulsion
of the fetus is apt to occur. Pyelitis rarely develops primarily in
pregnancy. It arises much more frequently after labor.

Hydronephrosis. — A displaced and adherent gravid uterus
may occlude the ureters, with this result. The condition requires
the reposition of the uterus.

A renal ealenlus is apt to induce abortion. Renal colic in
pregnancy is to be treated in the usual manner, without regard
to the patient's condition. The surgical treatment is not contra-
indicated.

Diseases of the Bladder. — Irritability is a functional disturb-
ance, and occurs in an exaggerated degree in hyperesthetic in-
dividuals, who feel acutely the pressure of the gravid uterus.
Some degree of irritability of the bladder is seen, as a rule, in
pregnant women.

The treatment /it diny IS required, may consist of the reposition
of a displaced uterus. If the disturbance is purely neurotic,
ner\'e sedatives are indicated.

addition to his own. The author has re«
**Ain. Joum. of Obstct.," July,

DISEASES OF THE BLADDER. 23 I

The incontinence of retention is one of the most distinctive
symptoms of a backward displacement of the gravid uterus.
There may be, however, a neurotic incontinence and a paretic
incontinence in pregnancy.

Vesical hemorrhoids are due to an increased blood-supply to
the part and an interference with the circulation by the pressure
of the pregnant uterus. Hematuria may be a symptom. If the
loss of blood becomes alarming, astringents may be injected into
the bladder ; the knee-chest posture should be assumed at fre-
quent intervals, and the bowels must be kept freely opened.

Cystitis is more frequent after labor than in pregnancy ; com-
plicating pregnancy, it may be due to gonorrhea.

Vesical Calculi. — It is important that vesical calculi be dis-
covered before labor. They should be removed through the
urethra or by vaginal lithotomy during the last month of preg-
nancy, so that if labor is induced by the operation, the child shall
not suffer by reason of its prematurity. It is unfortunate for the
woman if she fall in labor with an undetected stone in the
bladder. A vesicovaginal fistula is likely to be the result

Anomalies of the Urine in Pregnancy. — Polyuria is an ex-
aggeration of the physiological increase of the urine in pregnancy.
It sometimes reaches an astonishing degree. I have had under
my charge a woman who passed 220 ounces of urine a day.
There is usually great thirst and the urine has a very low
specific gravity, but should contain no albumin or sugar. The
woman's health remains unimpaired, and it is unwise to attempt
to diminish the excretion. After deliver)', the polyuria disappears.

The urine may be diminished in quantity, may be high colored,
and may have a high specific gravit>% as the result of errors in
diet and inactivity of the skin and bowels. This condition
should never be regarded with indifference. It shows an in-
creased strain upon the kidneys that may determine their break-
down. Meat should be temporarily excluded from the diet.
The bow^els should be kept open, and water must be drunk in
large quantities.

Upuria, occasionally observed in the pregnant woman, is ex-
plained by the unusual quantity of fat in all the tissues of the
body, making its way even into the blood-current. An oiled
catheter may be the source of the fat. This abnormality does not
necessarily affect the woman's general health.

Chyluria occasionally, but very rarely, apjxiars. It is of no
pathological import.

Peptonuria and acetonuria may develop in pregnancy in con-
sequence of fetal death or without ascertainable cause. The
latter condition is not infrequently a.«.sociated with eclampsia.

232 PREGNANCY,

The characteristic odor of the woman's breath may be well
marked.

Hematuria may be the result of vesical hemorrhoids. It may,
however, indicate acute cystitis, a vesical tumor, stone, or acute
nephritis.

Glycosuria in the pregnant woman ranks next in clinical im-
portance to albuminuria. It has been found by some observers
in from sixteen to fifty per cent, of cases, but this is not my ex-
perience. In the routine examination of the urine of all pregnant
women under my charge, I do not find sugar by Fehling's test
in one per cent, of the cases.

There are two distinct varieties of glycosuria in pregnancy.
One is due to absorption from the breasts, and the sugar in the
urine is lactose, and not glucose. There are no systemic symp-
toms in this variety. The other is true diabetes mellitus, which
is said to occur more frequently in pregnant than in non-preg-
nant women, ^ and if it exists before pregnancy is aggravated by
the latter condition. In 7 out of 19 cases the disease determined
fetal death, and in 4 out of 1 5 cases the mother died shortly after
labor. 2 Diabetes mellitus may appear in pregnancy with all its
characteristic symptoms and may disappear after labor. I have
one patient who regularly develops the disease in every preg-
nancy. It is not certain, however, to reappear in subsequent
gestations.

Albuminuria is found in about six per cent, of pregnant
women, as already stated. Its cause is the kidney of pregnancy
or nephritis.

DISEASES OF THE NERVOUS SYSTEM.

The Brain. — Tlie inflammatory diseases of the brain are acci-
dental complications of pregnancy and are rare ; they exert no
special influence upon gestation, nor do they modify its course,
except cerebrospinal meningitis, which is infectious, and therefore
has the same influence upon and is influenced in the same way
by pregnancy as the other infectious fevers. That is to say, it is
aggravated by the woman's condition and exercises a deleteri-
ous influence upon that condition.

Coiig:estion of the brain predisposes to apoplexy, an accident
which, serious as it is, has no influence upon the course of preg-

^ The idea that diabetes mellitus is more likely to occur in pregnant than in
non-nregiuuit women may have been due to the rather common appearance of lac-

of trae diabetes mellitus in women, reported by Griesinger
"^ in pregnant women.

Puerperal Diabetes," " Obstet. Tr," vol. xxiv,

DISEASES OF THE NERVOUS SYSTEM. 233

nancy or labor if the woman recovers from the cerebral hemor-
rhage.

The Spinal Cord. — Inflammatory diseases of this structure are
also accidental complications, and are without influence upon
pregnancy or labor.

Paralyses; — The woman may be the subject of paraplegia and
yet pregnancy and labor are entirely uncomplicated. The latter
process, indeed, is easier in such women. It would appear, there-
fore, that the spinal nerves exercise an inhibitory action upon
the uterine muscle, the removal of which facilitates parturition.

The Peripheral Nerves. — Obstinate neuralgias appear in preg-
nancy, which may be little benefited by treatment, and only
disappear after labor. It should be remembered that localized
pains of a neuralgic character in the head, face, or breast are
often indicative of advanced kidney disease in pregnancy. Mul-
tiple neuritis may have its origin in gestation, especially in
alcoholic subjects.

The Neuroses of Pregnancy. — Chorea. — The milder grades
of the disease are not uncommon in pregnancy. Buist ^ collected
225 cases. Sixty per cent, of the cases occur in primigravidae.
Heredity, chlorosis, rheumatism, and the existence of the disease
in the patient's childhood are predisposing causes. Chorea is
almost always aggravated by the coexistence of pregnancy,
though in one case recorded the chorea ceased when the woman
became pregnant. ^ In the graver variety of the disease premature
expulsion of the ovum is apt to occur, followed by death of the
mother in about one-fourth of the cases. Buist's statistics give
45 deaths out of 225 cases, — 17.6 percent. Insanity is not
infrequently associated with or follows chorea in the child-bear-
ing woman.

Treatment. — Fowler's solution, iron, nerve sedatives, change
of air, and nutritious diet are indicated in the milder cases. The
graver cases may actually require an anesthetic for the temporary
control of the violent movements until the induction of prema-
ture labor can be effected, whereupon there is usually a spon-
taneous recovery unless the termination of pregnancy has been
delayed too long.

Epilepsy is a rare complication of pregnancy. As a rule,
epilepsy does not influence unfavorably the course of gestation.
The convulsions are often absent during pregnancy, but make

1 "Trans. Edinb. Obst. Soc.," 1894-95.

' In a patient in the Maternity Hospital, a young girl illegitimately pregnant,
a chorea which she had had in childhood reappeared within a week of the fruitful
coitus. I was obliged to induce labor in the eighth month on account of the
severity of the s3rmptoms.

234 PREGNANCY.

their appearance again during and after the puerperium or upon
the reappearance of menstruation after the child is weaned. This
disease is most likely to be confused with eclampsia (see Eclamp-
sia). Cases have been reported in which the infant, after birth,
presented the symptoms of the maternal disease and died.

Hysteria occurs frequently during pregnancy in its minor
grades, but, as a rule, does not exert an unfavorable influence
upon the course or duration of gestation.

Tetany may have its origin in pregnancy.^ It is usually
mild in type, ending in recovery, but it may possibly end fatally,
in consequence of interference with respiration, by the firm con-
traction of the thoracic muscles.

Uncontrollable hiccup, vomiting, and coughing are usually
pure neuroses, and yield most readily, if they yield at all, to anti-
spasmodic remedies, or to a profound nervous impression.

Organs of Special Sense. — Eyes. — Failing vision should
always indicate an examination of the urine for signs of advanced
kidney disease. Occasionally, however, there occurs complete
temporary blindness, associated only with anemia of the eye-
ground, due to a reflex contraction of the retinal artery.

Hearing. — Disturbances of this sense are rare and are usually
temporary, but they may be permanent. They are often inex-
plicable. Some anomaly of the external auditory canal may be
found, as a hematoma, which was the cause in one reported
case of deafness in a gravid woman. In my experience the
hearing of a deaf person has been worse during pregnancy than
at other times.

Psychical Disturbances. — Insanity. — Frequency, — Of all
cases of insanity in women, about eight per cent, have their
origin in the child-bearing process. About one in four hundred
women confined become insane.

Predisposing Causes. — The nervous excitation of gestation in
women predisposed by hereditary influence to mental breakdown,
great reduction in physical strength, and prolonged mental strain
or worry should excite the physician's anxiety for his patient's
mind.

Exciting causes may be exaggerated anemia, as from prolonged
lactation ; septicemia ; albuminuria ; profound emotions, as exag-
gerated fear of impending danger ; the remorse and shame of
illegitimate pregnancy ; the grief of a deserted woman ; accidents,
as hemorrhage ; great physical or mental exhaustion. Chorea,
associated with iiwar** •^ther from the same predis-

* NeuBB "^

xlviii, H.

PSYCHICAL DISTURBANCES, 235

posing or exciting causes, and should not be considered in itself
as a cause of the insanity. In my experience, insanity in the
child-bearing woman has almost always resulted from some pro-
found emotion. One of my patients became insane after the
death of her child ; another, because her husband deserted her ;
a third, some days after her delivery, received a letter from her
seducer casting her off. She fainted on reading it, became a
raving lunatic that same night, and died of maniacal exhaustion
within two weeks. A number of women under my observation
have lost their minds from the shame of illegitimate impregnation.

Symptoms. — The form of insanity may be mania, melan-
cholia, or a condition of profound lethargy, stupidity, and mental
confusion. If a woman in this last condition is asked a question
in a sharp tone of voice, there is a momentary flicker of intelli-
gence in her face, but before the import of the question reaches
her brain, she is sunk again in her extraordinary apathy and
indifference to her surroundings.

Time of Occurrence, — Most frequently mental breakdown
occurs during the puerperium, next in frequency during lactation,
and least frequently during pregnancy. Mania is the most, mental
apathy or confusion the least, frequent form of puerperal insanity.
Melancholia is commoner in pregnancy than in the puerperium.

The diagftosis of insanity is usually easy. It is, however,
important to distinguish puerperal insanity from the temporary
delirium of labor, delirium tremens, the dehrium of fever,
especially that of septicemia, and from preexisting insanity.

The temporary delirium of iabor is common. It is usually
momentary, in the midst of the most acute suffering of labor,
and varies in degree, from an outbreak of -hilarity to violent
mania.

Delirium Tremens. — Labor, like an accident or surgical ope-
ration, may precipitate an attack in hard drinkers. The history
of the patient, and her symptoms, should demonstrate the nature
of the case.

The delirium of fever in child-bearing women is commonly
due to septic infection. It is frequently necessary to wait until
the fever subsides to determine if it be the cause of the mental
symptoms.

Prel^xistins insanity is recognized by the previous history of
the patient, if it can be obtained.

Prognosis, — About two-thirds of the women recover their
reason in from three to six months ; of the other third, from two
to ten per cent, die of septic infection or exhaustion ; the rest
remain permanently insane.

The treatment is best carried out in an asylum. Many patients,

236 PREGNANCY.

however, will not be allowed by their families to enter an
asylum. In such cases a modified rest-cure, combined with
administration of iron, arsenic, and a nutritious diet, together
with systematic exercise in the open air, will hasten the cure.
The most careful supervision must be exercised at all times, to
prevent the patient doing an injury to herself, her infant, or her
attendants.

DISEASES OF THE CIRCULATORY APPARATUS.

Under this heading are considered those diseases of the heart,
of the thyreoid gland, of the blood-vessels, and of the blood,
which have their origin in pregnancy or are much aggravated
by that condition.

The Heart. — Valvular disease of the heart usually antedates
impregnation. It may, however, owe its origin to septic infection
during the child-bearing process, or to rheumatism acquired
after conception.

Prognosis. — Abortion is induced in about twenty-five per
cent, of all cases, as the result of placental apoplexies, or of the
stimulation of the uterus to contraction by the accumulation of
carbon dioxid gas in the blood. Pregnancy distinctly increases
the danger of the heart-lesion. In fifty-eight serious cases,
twenty-three died after a premature delivery of the child. In
milder cases the prognosis is not grave, yet the woman's con-
dition is by no means free from danger. The complications
particularly to be dreaded during gestation are : afresh outbreak
of endocarditis, fatty degeneration of the papillary muscles, and
especially, congestion of the lungs. If the disease be of long
standing and serious in character, it appears, from statistical
studies, that about half the women will die.^ If there is good
compensation, however, there may not be an untoward s^inptom,
or, at most, occasional palpitations, some dyspnea, edema, and a
tendency to renal congestion, with albuminuria.

Treatment. — The pregnant woman with valvular disease of the
heart must be carefully watched. Her urine should be examined
at frequent intervals. On the first appearance of symptoms
pointing to inadequate compensation, digitalis or strophanthus
must be administered, and it is commonly necessary to increase
the dose as pregnancy advances. The bowels must be kept
freely opened. Moderate exercise in the open air is an advan-
tage, but rest in the recumbent posture must be ordered at fre-
quent intervals during the day. Meat should be eaten sparingly

^ This is not, however, my experience ; with proper treatment I have no fear of
heart disease in pregnancy (see Dystocia).

DISEASES OF THE CIRCULATORY APPARATUS, 237

on account of the likelihood of kidney breakdown, and extra pre-
cautions must be taken against suddenly throwing greater work
upon the kidneys by chilling the skin. Flatulent dyspepsia is
not infrequent in cardiac weakness. It should be carefully
treated. It is almost unnecessary to state that the woman must
avoid any sudden, violent physical effort, and should be spared
any cause for mental excitement. Finally, pregnancy should
never be allowed to continue longer than the thirty-sixth week
in a woman who exhibits any symptom of imperfect compensa-
tion.

The Heart-muscle. — Suppurative myocarditis is only seen
in connection with septic infection. Brown atrophy of the myo-
cardium has been noted as a very rare complication of preg-
nancy ; fatty degeneration of the heart-muscle may occur acutely
in consequence of general systemic septic infection, or as a result
of the accumulation of poisons in the blood when the kidneys
are functionally insufficient.

Graves' Disease and Goiter. — These diseases are unfavor-
ably influenced by pregnancy. The former may have its origin
in gestation. It predisposes the woman to uterine hemorrhages
and may be a cause of fetal death. It may and usually will dis-
appear after delivery. I have one patient in whom exophthal-
mic goiter with all its classical symptoms has recurred regularly
in three successive pregnancies, the woman at other times being
quite free from the disease. A goiter may take on so exag-
gerated a development during pregnancy that asphyxia is
threatened, and tracheotomy may be necessary.

The Blood-vessels. — The disease of most clinical interest in
these structures is varicose veins in the rectum, anus, broad
ligament, bladder, vagina, external genitalia, the abdominal walls,
and lower extremities. In the last there may develop a pressure
edema, associated usually with varicose veins.

The causes of varices in pregnancy are changes in the invest-
ing muscular sheath of the veins, the increased quantity of blood,
and mechanical obstruction to the circulation by the bulk of the
growing uterus. Atheroma and degenerative changes may be
found in the vessel -walls as the result of kidney insufficiency.

Complications. — There may be rupture, with possibly a fatal
hemorrhage, a severe interstitial bleeding, or extensive extravasa-
tion of blood under the skin. Thromboses and phlebitis, with
suppuration and septic infection, may occur. As the result of
itching and scratching, eczema or even erysipelas of the affected
part may develop.

Treatment, — An elastic bandage or stocking should be
ordered for varices of the legs. Small doses of heart-tonics are

238 PREGNANCY.

often of service. Constipation must be avoided. The patient
should be advised to He down at intervals during the day. Abso-
lute rest must be ordered in cases of thromboses, to prevent em-
bolism. Lead-water and laudanum should be applied when there
is any inflammation. Abscesses along the course of a diseased
vein should be opened early. A mechanical protection (soap-
plaster) should be applied to the affected part to prevent the
development of eczema or of erysipelas. Itching may be relieved
by weak solutions of carbolic acid or by cocain. The woman
herself should be instructed how to check hemorrhages, in case
the distended veins burst.

Aneurysms are naturally unfavorably affected by pregnancy.
The hypertrophy of the heart, the increased quantity of blood, and
the mechanical interference with the circulation in gestation are all
unfavorable factors. Such a case should be managed on the
same principles that govern the treatment of cardiac complica-
tions. By this plan I have successfully delivered a young
woman with an enormous aneurysm of the arch of the aorta.

The Blood. — Pregnancy may have a decided influence in
producing those blood diseases which are characterized by a
marked alteration in its constituent parts. Pernicious anemia and
leukemia may have their origin in gestation, and should they
already exist, they are aggravated by the existence of pregnancy.
Pregnancy should be promptly interrupted if these blood diseases
are obviously progressing from bad to w^orse. The anemia of
pregnancy may be so exaggerated as to appear pernicious, but
arsenic, iron, and nutritious diet after delivery will usually effect
a cure. Purpura luBinorrhagica is apt to be rapidly fatal in preg-
nancy, which it always interrupts. The disease usually destroys
the fetus before it is expelled. The maternal death may be due
to postpartum hemorrhage or to sepsis.

DISEASES OF THE RESPIRATORY APPARATUS*

The Nose. — ^The sense of smell may be more acute, and
peculiarities in this sense are developed, as abhorrence for certain
odors, which may excite nausea and vomiting in neurotic indi-
viduals.

More important is the disposition to epistaxis, which may be
•*" *»n life. Epistaxis, however, is a more

rturition than of pregnancy. It can
•^i termination of labor. Meanwhile

■ibercular or syphilitic disease be

DISEASES OF THE RESPIRATORY APPARATUS. 239

present, there is a constant danger of edema of the glottis, which
will require tracheotomy.

The Bronchi and Lungs. — Bronchial catarrh ordinarily is not
harmful, but prolonged coughing may cause abortion, and the
hydremic condition of the blood in pregnancy predisposes to
pulmonary edema. The cough may have a neurotic clement in
it, and may be most persistent. In its treatment I have obtained
better results from oil of sandalwood than from any other single
remedy.

Pneumonia. — The symptoms of this disease are much aggra-
vated by gestation, the mortality is increased, and in the vast
majority of cases the fetus is prematurely expelled (see
Pathology of Puerperium).

Emphysema is quite common. The symptoms in a pregnant
woman are aggravated, and abortion is apt to occur. In ad-
dition to the usual treatment inhalations of oxygen may be
given to counteract the accumulation of carbon dioxid in the
blood, which stimulates the uterine muscle to contract, and thus
is the chief factor in determining an interruption of pregnancy.

Asthma in some women may only appear during pregnancy.
In such cases the disease disappears the moment gestation is
terminated. In other cases asthma may only appear in labor.
In asthmatic subjects the attacks may be much aggravated by
gestation and may obstinately resist all treatment. Radical
change of air and scene has proved efficacious when all medicinal
remedies have failed.

Phthisis Pulmonalis. — The influence of pregnancy upon this
disease is most unfavorable, and in women predisposed to tuber-
culosis gestation may be the determining factor in lighting up an
attack. There is a superstition prevalent among the laity that
pregnancy is beneficial to a phthisical patient. This idea has its
origin in the accumulation of fat commonly seen in the pregnant
woman, which gives her a fictitious appearance of improved
health. In reality the strain and drain of child-bearing exhausts
the vitality of the tuberculous subject so seriously that her death
is hastened by many months, and a pulmonary phthisis that
might have been arrested becomes incurable. It is the duty of
a physician to advise strongly against marriage and maternity in
the case of a woman already infected with or predisposed to
tuberculosis.

Miliary tul>erculosis is rapidly fatal in pregnancy or shortly
after delivery. It may be mistaken for septic infection. I have
seen several cases in child-bearing women in which this mistake
was made. The diagnosis is extremely difficult to make.

Pulmonary embolism is a possible accident in pregnancy.

24*

PREGNANCY.

glycosuria dietetic management is required. A boric-acid oint-
ment on the skin will protect it until tlie sugar in the urine is
reduced in quantity.

There are three domestic remedies that enjoy a consider-
able reputation : very hot fomentations, vinegar, and infusion of
tobacco. The last must be used sparingly and cautiously. The
best medicinal applications are cocain, mentiiol, and carbolic-
acid preparations.

The pruritus dependent upon seat-worms is treated by rectal
injections of iiifu.sion of quassia.

ExaxKerated PlKmentation. — Spots of quite dark pigmentation
may appear on the breasts, thighs, and abdomen, as large as ten-
cent pieces or a quarter of a dollar. The chloasmata on the face
may be so exaggerated as to disfigure the countenance. This
skin affection disappears after delivery, and is not amenable to
treatment during pregnancy.

Loosening; of the finder nails is a painful affection of pregnancy,
apparently dependent upon malnutrition, and usually appearing
in neurotic individuals. Nerve tonics, especially strychin, good
hygiene, and a general tonic treatment do something to arrest the
progress of the disease ; but in the few cases under my observa-
tion (one recurring in three successive pregnancies) the treatment
was only palliative as long as pregnancy continued.

Injuries and Accidents. — ^Severe injuries to a pregnant
woman usually result in abortion. Among the most serious
accidents of pregnancy are nipture of varicose vrins in the ex-
ternal genitalia, the vagina, or lower extremities. One of the
rarest accidents of pregnancy is rupture of the uterus. It may
occur spontaneously in consequence of a previous Cesarean sec-
tion, a myomectomy, or a healed rupture of the uterus at a former
labor, the scar bursting open ; it may be the result of chronic
inflammation and degeneration of the uterine walls, reducing
them to little more than connective tissue ; or it may be due to
traumatism. Spontaneous rupture of the uterus in pregnancy
almost always occurs at the fundus, and frequently at the pla-
cental site. The accident is almost invariably fatal to both
mother and child. .\ \'er)' scriou.t acciiient of pregnancy is de-
taclim^'i " " ■; . ■ ■ i, with concealed internal

hcmon;

Surv

!■ health

ABORTION. MISCARRIAGE, AND PREMATURE LABOR.

243

tion if sqjtic infection is avoided. My friend, Professor W. W.
Keen, successfully amputated the thigh at the hip-joint for sar-
coma in a woman five months pregnant, without interrupting
gestation. Tumors of the pelvic regions may be excised with
no more risk of abortion than any woman runs (twenty per cent).
It is even possible to remove a myoma from the uterine wall
without inciting uterine contractions. I had the privilege of
assisting Dr. Wm. J, Taylor in a myomectomy on a woman some
four months pregnant. The tumor was enucleated from the
uterine wall, leaving a raw surface as large as the outspread hand.
The woman was prematurely delivered, but it was some time after
the operation, which appeared not to have caused the miscarriage.
In nervous and irritable women, however, slight operations, such
as the extraction of a tooth may interrupt gestation. The proper
course, naturally, is to avoid operative interference in the preg-
nant woman, if it can be deferred without serious detriment to the
patient. If, on the contrar)', there is a positive indication for
immediate operation, It should be undertaken witliout hesitation.

ABORTION, MISCARRIAGE, AND PREMATURE LABOR.

The term "abortion" is usually applied to the expulsion of
the ovum before the fourth month, at a time when the placenta
is not yet fully differentiated from the remainder of the chorion.
Premature labor signifies the birth of a fetus that is viable. For
the expulsion of the ovum during the intervening time from the
fourth to the sixth month of pregnancy a distinctive term is
needed, as the process, in combining some of the features of both
abortion and premature labor, presents a clinical picture different
from either of them. To denote the interruption of pregnancy
at this time the word " miscarriage " will here be used.

The Causes of Premature Expulsion of the Ovum. — Many
of the conditions which inlcrnijit the course of pregnancy have
been referred to. The death of the fetus : abnormalities and
diseases of the membranes, including the deciduie; pathological
conditions of the placenta and apoplexies of the ovum ; trau-
matism and certain diseases of the mother have all been noticed.
But the maternal diseases have been regarded chiefly as to their
effect directly upon the embryo, fetus, or ovum. There are,
however, certain conditions of the mother having as their primary
efiect tlie active contraction of the uterine muscle, which results
secondarily in the premature expulsion of the ovum, although the
latter may be norma! in every respect. Under this head come :
■table Uterus. — From clinical observation one must feel in-
D ascribe to every uterus a special temperament, which.

244 PREGNANCY,

as the case may be, is irritable, equable, or apathetic. It is
notorious that some pregnant women are liable to lose the
product of conception from a trivial cause. A long walk, coitus,
congestion of the pelvis from any cause, ovaritis, irritation of the
breasts or nipples, the extraction of a tooth, irritation of the
vulva, a dose of some mild purgative, the jolting of a carriage ;
a misstep, especially while descending a staircase ; not to mention
a sea-bath, exercise on horseback, or dancing, have been followed
by expulsion of the ovum. The mere sight of another woman
in labor has been sufficient cause for abortion in some nervous
women. In case the disposition of the woman to abort is known,
the greatest care must be exercised to guard her from anything
which might stimulate uterine contractions, and at the time corre-
sponding to the menstrual period, when the uterus is particularly
irritable and prone from habit to contract, the precautions must
be doubled.

The opposite picture, while not so familiar, is occasionally
seen. Some women can make the most violent exertion, can
receive the roughest treatment, without bringing pregnancy to
an end. English writers tell of women who follow the hounds
over the most difficult country in the early months of pregnancy
without aborting. Sounds have been introduced into the preg-
nant uterus ; intra-uterine injections have been given ;^ strong
applications have been made to the endometrium ; trocars have
been plunged through the uterine wall ;2 a pregnant woman has
been thrown violently from her carriage ;^ another fell from a
third -story window, fracturing her skull and breaking a leg ;** in
one case a young girl, five months pregnant, cast herself from
the Pont Neuf into the Seine ;^ in another, fifteen leeches were
applied to the cervix of a pregnant uterus ; Emmet's operation
has been performed upon the cervix during the second month
of pregnancy ; ovariotomy and other serious surgical operations
have been repeatedly performed, — all without inducing abortion
or premature labor.

Spasmodic Muscular Action in the Mother as a Cause of Prema-
ture Expulsion of the Ovum. — Pregnant women affected with cho-
rea, eclampsia, uncontrollable vomiting or coughing, epileptic,
hysterical, or cholemic convulsions, or with tetany, are very liable
to expel the product of conception prematurely.

1 Scanzoni, <* Lehrbuch d. Geb.," Wien, 1867, p. 83.

' Many cases are reported of tapping a uterus distended by hydramnios in mis-
take for an ovarian cyst or ascites.

■ '**H ed., p. 567. Also two of my patients.

*%ilade}phia Hospital. She recovered from her
Pregnancy, and was delivered at term.

bstit. et de Gyn6c.," 1886, p. 1645.

ABORTION, MISCARRIA GE, AND PREMA TURE LABOR, 245

Cliorca, — Less than half of the women affected with chorea
gravidarum will go to term. Of 57 cases collected by Barnes,
only 22 completed the full time of pregnancy. Bamberg's
statistics of 64 cases show 33 arrived at term, and Spiegelberg,
of 69 cases, saw only 29 delivered of mature infants. ^

The reason for the premature termination of pregnancy in
these cases is not quite clear. Perhaps the physical exhaustion
due to almost incessant muscular action explains it. It may be
that the muscular contraction disturbs the venous circulation,
brings about a stasis in the uterine veins and a consequent excess
of carbonic oxid gas, which may excite the uterine muscle to
action (Brown-Sequard). In a case recently under my observa-
tion the uterine muscle toward the end of pregnancy seemed to
take part in the choreic movements that convulsed the muscles of
the extremities. Through the abdominal wall the uterus could
be felt firmly contracting at intervals of not more than a minute.
Every contraction was extremely painful, but during the four
days that this condition of the uterus lasted the os showed no
signs of dilatation. The suffering finally became so great that
labor was induced by Krause's method. ^

Eclampsia. — The eclampsia of pregnancy in the great majority
of cases determines the premature expulsion of the ovum. Fre-
quently, no doubt, the life of the fetus is first destroyed ; often,
however, the immediate effect is seen in expulsive efl!brts of the
uterus, due to the asphyxia of the organ, to the irritating effect
of urea, carbonate ammonia, or excrenientitious products in the
blood, or perhaps to the fact that the uterine muscle shares in
the convulsive action of the whole muscular system.

Uncotitrollablc Vomititin' atid Coiti^hifii^. — The constant violent
action of the diaphragm in cases of uncontrollable vomiting dur-
ing pregnancy often leads to the expulsion of the ovum. Of
51 cases of uncontrollable vomiting collected by Gueniot, 20
ended in abortion or premature labor. -^ A violent and per-
sistent cough will also, in rare instances, by the constant succus-
sion in the abdominal cavity, be the cause of premature expul-
sion of the ovum.

Epileptic, Hysterical, Choi c mi c, ami Tctamnd Convulsions. —
According to Tamier, attacks of epilepsy during pregnancy can
be disastrous for the fetus, either in killing it outright or in bring-
ing about its premature expulsion. Tanner mentions a case of
hysterical convulsions which was followed by the expulsion of a

» Herv6, " Thdsc de Paris," 1884.

' For a report of the case see " Trans. Philadelphia Obstet. See.," Dec, 1887.

• Tamier et Budin, op. cit. , p. 59.

246 PREGNANCY,

dead fetus at the seventh month. ^ Cholemic convulsions occur
perhaps more frequently than is generally suspected, 2 and they
always interrupt pregnancy, either by the death of the mother or
the expulsion of the ovum. Meinert ^ has collected 1 1 cases of
a tetanoid condition in pregnancy, in 6 of which there was true
tetany. In 2 of the 1 1 cases dead children were born, i
prematurely at the seventh month, the other at term. In one
other case the child was expelled at the eighth month, and in
another eleven days before term.

Conditions of the Maternal Blood which Stimulate the Preg^nant
Uterus to Contract. — The poisons of all the infectious diseases in
the maternal blood are likely to excite active contractions in the
pregnant uterus. Whether this is due to some irritative action
of the micro-organisms, or to the development of toxins, or to a
diminution of the oxygenating power of the blood, as yet re-
mains in doubt. The last condition explains the abortions
occurring in pneumonia, as well as in cases of chronic heart
disease, in which the circulation is much interfered with. It is
possible also that strong emotions alter the blood in some way
that would account for the action of the uterus when women
have been terrified. But it is more likely that the action
is analogous to that of the rectal and vesical muscles in
cases of nervous defecation and urination. Thus, Baudelocque
said in his lectures that, after the explosion of the powder-mill
of Grenelle, he was called to sec sixty-two women, either aborting
or threatened with abortion. In all maternal diseases accompanied
by fever the thermic irritation of the uterine muscle might be
held responsible for the expulsive cfibrts of the uterus, but there
are in these cases other conditions offering a more probable
explanation for the abortion.

Uterine Contractions Excited by an Abnormal Situation or Posi-
tion of the Uterus. — Retroflexion and prolapse of the gravid uterus
may induce abortion, for the uterus is unable to expand properly
in its unnatural position. This is true likewise of pregnancy in
one horn of a bicornate uterus.**

Perimetritis also, resulting in adhesions between the uterus
and neighboring organs, or cellulitis, with plastic exudate in the
broad ligaments, as well as diseases of a tube and ovary leading
to adhesions, will, if pregnancy should occur, usually interrupt
its course by interfering with the expansion of the gravid uterus.
Appendicitis, with adhesions involving the uterine adnexa, may

Tuuicy," London, 1867, p. 304.

^j L Gyn.," Bd. xxxi, S. 444.

"^ Horn of a Doable Uterus, with
triCi," 1887, pp. 337, 346.

ABOR TION, MISCARRIA GE, AND PREMA TURE LABOR, 24/

also have the same result. Fibromyomata of the uterine wall
may act in the same manner, or else, by the congestion of the
organ to which they lead, or by acting as a mechanical irritant,
may stimulate the uterine muscle to contraction.

Overdlstention of the Uterus as a Cause of Premature Expulsion
of the Ovum. — If the uterus is unduly distended in hydramnios
or in cases of multiple pregnancy,^ especially when there are
three or more fetuses, the distention of the muscle may irritate it
to expulsive efforts.

In twin pregnancies, should one fetus die, the uterine muscle
is occasionally stimulated to contraction, and the entire uterine
contents are cast off, although the remaining fetus may be healthy
and normal. In cows epidemics of abortion have been observed,
which have been attributed to a specific form of micro-organism,
said by Franck and Rolofif to resemble the leptothrix buccalis.^
Brocard ^ has also called attention again to this disease. It is
improbable that the same disease can affect a woman, but in
lying-in hospitals an epidemic of abortion or premature labor
might occur from septic infection during pregnancy.

Clinical History of Abortion and Miscarrias^e. — Premature
labor is not referred to. Its course, management, complications,
and after-treatment may be considered in the description of labor
at term, from which it does not materially differ.

The Frequency of Abortion. — It is almost impossible to
arrive at a correct estimate of the frequency of abortion. So
many women lose an impregnated ovum at an early period of
its development, when they arc not conscious of being preg-
nant ; so many others fail to seek medical advice for an abortion
uncomplicated by hemorrhage or decomposition of retained
secundines, that almost all the estimates cf the relative fre-
quency of abortion and labor at term place the figure for the
former too low. Hegar "* says that one abortion will occur to
every eight or ten labors at term ; but the estimate of Guillemot
and Devilliers,^ of one abortion to every four or five pregnancies,
is doubtless more nearly correct, — an opinion in which Tarnier
coincides. Priestley^ found that 400 women, among whom there
had been 2325 pregnancies, gave a return of 542 abortions, or
about one abortion to every four pregnancies. My own case-
books also show this proportion.

» Sec Dol^ris, « Nouvelles Archives d'Ohst^t. et de Gyn^c," 1886, p. 318.
'Schroeder, *« Geburtshulfe," 8. Aufl., 1884, p.460.

• •* Recherches sur rAvortement ^pizootique des Vaches," Broch., Paris, 1S86.

• "BeitrSge zur Pathologic des Eies,'* "Monats. f. Geburtsh.," Bd. xxxi, S. 34.

• Tarnier et Budin, op. cit. , p. 474.

*« Pathology of Intrauterine Death,'* London, 1887, p. 8.

248 PKEGXANCY.

Clinical Pbenomena of Abortion. — The main clinical phe-
nomena of abortion are; (l) Hemorrhage, (2) pain, and (3) the
expulsion of more or less characteristic portions of an impreg-
nated ovum. But these symptoms are rarely all maniftsted in a
typical manner in every case. Pain may be absent, hemorrhage
not excessive, and the whole ovum when cast off so small that it
escapes unnoticed among the clots of blood that are discharged
from the uterus. Such cases occur shortly after conception, and
often pass for disordered menstruation, while the fact that preg-
nancy had begun is not suspected.

The duration of abortion varies to an extraordinary degree.
The French speak of an avorlemcnt inslantanc and Cazeaux
gives an example of a woman who fell upon her buttocks,
and, on rising, found on her linen considerable blood and a

■ six-week ovum. In some cases the expulsion of the ovum
I may occupy about the time consumed in a normal labor, but
I very frequently the process is a much slower one. Days, and

■ even weeks, may be required for the uterus to get rid of its
contents if left unaided to nature, and it is not rare for a fragment
of the placenta or a portion of the uterine decidua to remain
behind indefinitely, firmly attached to the uterine wall and often
continuing to grow and develop, constituting within the uterus a
true pathological new formation.' Of the two symptoms, pain
and hemorrhage, the former is, in early abortions, usually the sub-
ordinate one. The hemorrhage is not oltcn excessive, but may
become alarming. The blood is not expelled in a steady flow.

<a described under the n

" ItUcentsl polyp," " polypoid li

ABOKTWX, iVrSCARRlAQE. AND PRKMATCfiE LABOR. 249

but from time to time as coaffula. When the uterus discharges
its contents the appearance of the substance expelled differs
as the ovum is cast off entire with its shaggy, chorional coat, or
surrounded by the decidua, which is often much tliickened ; as

Fig. 154.— Thickened deci
forming casl of uterine cavity. C
emply (Hodge ObKclricaU'oUec
Universilf of Poinsylvaiiiu).

^'E' 'SS* — An embryo in its c
; SBC (from the Hodge ObslelriCBl
lion of ihe Univenily of Pennsylvn

the embryo, enveloped by its amnion, is extruded without the
decidua and chorion, or as the embryo, its dthcate umbilical
cord being ruptured, is expelled alone. The appearance of the
embryo will, of course, vary with the different periods of preg-
nancy : if still inclosed in its amni-
otic sac, a thin-wallcd. transparent
vesicle may be found floating in the
blood or imbedded tn a clot, and
within the sac the embryo is seen
floating in the liquor amnii. In
other cases the ovum resembles
a ball of flesh, which, on being
opened, discloses an embryo con-
fined within a sac with ver>' thick ^ig 156.— Embryo of about i<.ur
walls, composed mainly of greatly wcek», wilLilsinembraiiesenlite.

hypertrophicd decidua. Or, again.

the substance expelled from the uterus may be a fleshy mass,
the deciduous membrane, in shape a cast of the uterine cavity,
within which there is an empty cavity. The embryo in these
cases has either died and bt^n absorbed, or else has been pre-
viously cast off unnoticed in the bloody discharge.

250 PREGNANCY.

If the ovum proper is cast off entire, — that is, with its cho-
rional covering intact, without adherent shreds of deciduous
membrane, — it presents an appearance quite characteristic, espe-
cially if floated in water ; the chorional villi show to the best
advantage, giving the ovum much the appearance, except for its
color, of a chestnut-bur.

Most frequently it is the embryo alone, or at most the ovum,
in whole or in part, covered often by the ovular decidua that is
cast off, while the uterine decidua remains behind within the uterus.

Duhrssen,^ from a rich experience in the service of the
Charite in Berlin, says that "the retention of portions of the
decidua vera is not the exception, but the rule" ; and Tamier
says that "ordinarily the uterine decidua remains adherent to
the uterus." The retention of this membrane after abortion can
not be regarded with indifference, for the uterine mucous mem-
brane in the early part of pregnancy, greatly hypertrophied and
thickened, before it has undergone the physiological atrophy
that begins in the third month is very different from the delicate
membrane which lines the uterus at term. This thickened uter-
ine decidua, suddenly cut off from the greater part of its blood-
supply by contraction of the uterine wall, becomes a mass of
dead animal flesh within the uterus, and soon begins to putrefy,
or else portions of the decidua attract an increased blood-supply,
retain their original development, or even increase in size, form-
ing new growths within the uterus which give rise to frequent
and alarming hemorrhages.

It is this complication of abortion that often makes the prog-
nosis uncertiin, and is perhaps the main factor in raising the
mortality after abortions almost as high as that of childbirth i
term. In New York City, between the years 1867 and iS/j.
inclusive, 197 deaths were reported as a result of abortioii,-
number doubtless far short of the truth. In the Rotunda J"
pital of Dublin, during the mastership of Dr. Johnston,
abortions occurred, with but i death, and that from heart
ease. ^ But of 120 cases treated in the clinic ;ind polyclij
the Charite in Berlin, 2 died.* Of 82 abortions ' " *"
rical and Gynecological Institute of Florence,'' 5 rcsulte

■ •' Zur Patliologie uiij Tlierapie dcs Abortus," "Arcliitf f, Gjn.

> Lusk's " Olisletrics," 1S86, p. 313.

• Duhrsscn, Im. cit, Tliia s.mie aiiihni mention? (he stalislic*
alnrtion cnllerlL-d in thF in.-iu^rnl t)u'si« of UcIiIlt llterlinj. Half,
liy active interference, allowed 4 ileallis.^j from inlctcuncnl affar

•Fasola, "Sj aborii nil Irifinio, iXKj-^s,'' - Atioali di <
Mareh, 18S7.

ABORTION, MISCARRIAGE, AND PREMATURE LABOR, 25 1

to the women, — a death-rate of six per cent. In the Charite at
Paris (1883—86) there were 57 cases of abortion without a death ;
and in the Matemite, 153 cases with i death (Tamier). Hos-
pital statistics, however, as to the death-rate after abortion, are
unsatisfactory. The reliable records of some large out-door dis-
pensary service would tend to throw light upon the matter.

Diag^nosis. — It may be necessary in cases of suspected abor-
tion to determine the existence of pregnancy ; that fact being
established, it becomes necessary to distinguish between threat-
ened abortion, inevitable abortion, and an abortion partially or
wholly accomplished.

The Dias:nosis of Threatened Abortion. — If a patient should
present a history of suppression of the menses, perhaps for only
one period ; if it could be learned that she had been exposed to
the possibility of impregnation ; if there were, in a word, the
signs of early pregnancy, and a hemorrhage should occur from
the uterus, associated witli more or less pain, the supposition
that an abortion was threatened would be justified. Irregularities
in menstruation, the suppression of the function from causes
other than pregnancy, and its rcestablishment by a profuse
flow, accompanied by pain, might well arouse a suspicion of
abortion. In these cases, however, the signs of pregnancy are
absent and the os is not patulous. This is by no means true
of every case, however ; and if the symptom should be due to an
effort of the uterus to expel a polypoid tumor, the case may so
closely resemble one of abortion that the diagnosis is only made
after the expulsion of the uterine contents or the dilatation
of the OS. In cases of doubt the diagnosis should rest on
abortion and the treatment should be adapted to this idea.

The Dlas:nosis of Inevitable Abortion. — It is always desirable
to determine when a threatened abortion becomes inevitable, for
if its prevention is no longer possible, the treatment should
be radically altered. Unfortunately, however, the signs which
usually denote an unavoidable expulsion of the ovum are not
always to be depended upon. If there is persistent hemorrhage,
abortion will usually occur, but even in spite of a bleeding which
may continue for a considerable time or return at intervals dur-
ing the whole duration of pregnancy, the case may go on to
term. If the cervix becomes markedly softened and the os
dilates, the ovum will ordinarily be cast off; and yet the os has
dilated sufficiently to admit two fingers, but has again retracted,
and pregnancy has pursued its course. If portions of the uterine
contents should be expelled, it would seem that abortion was
surely inevitable ; but Pla>^air, Charpentier, and Doleris have
reported cases in which pieces of decidua were expelled from the

2S2 PREGNANCY.

uterus without the interruption of pregnancy. In Playfair's case
four or five fragments of decidua, each as large as a fifty-cent
piece, were cast off in the third month of pregnancy as a result
of the introduction of a sound into the uterus ; but the woman
went on to term. The only two conditions which can be said
to render the abortion almost inevitable are the rupture of the
membranes and the death of the embryo ; but even were it pos-
sible to ascertain with certainty, during the early months of
pregnancy, that the membranes were ruptured or that the embryo
was dead, cases might be recalled in which the liquor amnii was
resupplied after puncture of the pregnant uterus with the trocar
(Chiara), or many other cases might be collected of the retention
of an ovum after the death of the embrj-o for months or for an
indefinite number of years. If, however, the hemorrhage is per-
sistent ; if the os dilates ; if there is felt presenting within the os
a cystic tumor — the ovum ; ^ if the pain is considerable ; and,
above all, if portions of the ovum are expelled, the abortion may
be pronounced inevitable. Tarnier^ calls attention to another
sign which he believes to be valuable as indicating an unavoid-
able abortion. This is the effacemcnt of the rather acute angle
formed anteriorly between the neck and body of a pregnant
uterus. The disappearance of this angle indicates a contraction
of the longitudinal fibers of the uterus and a descent of the ovum.
The Diagnosis of an Abortion Partially or Wholly Accomplished.
— It is always important to determine, in a case diagnosticated as
one of abortion, whether a part or the whole of the uterine con-
tents lias been expelled. To make the diagnosis of an abortion
partially or wholly effected it is necessary to examine everything
discharged from the uterus ; the clots should be floated in water,
and should be carefully teased apart, when an embryo, alone or
en\-elopcd b>- its membranes, may be discovered. But frequently
the embrj'o and ovum are so small that tliey are lost in the com-
paratively great volume of blood that surrounds thera, or the
discharges are removed from the patient and are not preserved.
In such cases an internal digital examination ordinarily serves
to determine the true nature of the case. The os is usually
found patulous ; the finger, passing into the cavity of the uterus,
detects shreds of deciduous membrane more or less closely
attached to the uterine wall, and often a placenta, still adhe-
rent, or some portions of the fetal membranes may be plainly
distinguished. If thu abortion fa^ been wholly accomplished,

ABORTION, MISCARRIAGE, AND PREMATURE LABOR, 253

— that is, if all the uterine contents, including the hypertro-
phied decidua, have been completely expelled, — the uterus is
firmly contracted, the os is small, and a digital examination
of the uterine cavity is difficult or impossible. The diagnosis
must depend upon the history of the case, upon the examination
of the discharge, upon the enlarged uterus, — which does not at
once return to its normal size, — upon the lochial discharge, and
upon the establishment of the milk secretion. The last phe-
nomenon is all the more marked the later the date of pregnancy
at which abortion or miscarriage occurs, and is more evident in
multiparae than in primiparae ; but Budin has observed a young
girl in whom the menses were suppressed for only twenty days,
and then returned as a profuse flow, who exhibited shortly after-
ward all the signs of commencing lactation.

In some cases the disappearance of all the presumptive signs
of pregnancy, which had been before well marked, would justify
the opinion that an abortion had occurred ; but it might d note
nothing more than the death of the embryo, which can be re-
tained within the uterus for varying periods of time, and when
cast off may give rise to unjust suspicions as to the woman's
moral character. Thus, if a woman whose husband has been
absent many months should expel from her uterus an embryo
corresponding perhaps to the second month of intra-uterine life,
it by no means invariably follows that she has been unfaithful.

Finally, if in the early months of pregnancy there is hemor-
rhage and a discharge of deciduous membrane, it would be well,
while making the digital examination, to feel on either side of the
uterus for a tumor that might indicate a tubal pregnancy, and to
inquire for the characteristic pain of that condition.

Pros^nosis of Abortion and Miscarriage. — The prognosis
as regards the product of conception need not be considered,
for its destruction is inevitable. Statistics have been already
given showing that every abortion or miscarriage entails a cer-
tain amount of risk upon a woman. The hemorrhage, if rarely
so great as to be immediately fatal, may, by its persiistence, so
weaken a woman that she quickly succumbs if attacked by any
intercurrent affection, or the syncope produced by Joss of blood
may favor the formation of heart-clot. The retention of masses
of deddua or of the placenta is often followed by the decom-
position of these substances /;/ utero, chronic salpingo-oophoritis,
or even by fatal septicemia as a result. Tetanus is another
complication post abortum which, in rare cases, helps to raise
the mortality of abortion.^ Criminal abortions, with the addi-

^ For twenty-one cases of tetanus after abortion see Bennington, ** British Gyn.
.," 1885.

254 PREGNANCY.

tional risk of traumatism from the unskilful use of instruments,
and the probability of infection from unclean hands and imple-
ments, would probably show a very high rate of mortality if it
were possible to collect accurate statistics. The prognosis of
abortion depends in great part upon the treatment If every
case could be treated by an aseptic curetment at the hands of a
skilled gynecologist, the mortality of abortion would be nil.

Treatment. — If a pregnant woman presents any of the con-
ditions which a physician's experience or knowledge teaches him
may lead to the premature interruption of pregnancy, the treat-
ment of these conditions will constitute the preventive treatment
of abortion. Much has been said upon this subject when the
diseases of the embryo and fetus and of the ovum were under
consideration. The proper conduct to pursue in the other com-
plications of pregnancy just described may be briefly indicated.

In cases of irritable uterus the woman must be jealously
guarded against any nervous shock, undue physical exertion,
errors in diet, sexual intercourse — anything, in a word, that
would furnish the uterus an excuse for throwing off its contents.
In exaggerated cases of this condition prolonged rest in bed,
especially at the time corresponding to the menstrual periods,
or perhaps for the whole duration of pregnancy, may be neces-
sary to secure the birth of a mature infant. If the pregnant
uterus is displaced downward or backward, it must be restored
to its proper position, and be kept in place by a suitable pessary
until its increasing size prevents it.s displacement again. If there
should be uncontrollable vomiting or coughing, these conditions
must bo treated appropriately. Asthma, which in some cases
will determine a premature interruption of pregnancy, is best
treated by change of climate. ^ In general muscular spasms,
as in eclampsia, cholcmia, chorea, epilepsy, hj'steria, and tetany,
the convulsions must be combated by appropriate remedies.
The infectious and febrile diseases of pregnancy must be man-
aged on general principles, without special regard to the danger
of abortion, which is often unavoidable. Chronic metritis and
endometritis, fibromyomata of the uterus, lacerated cervix, peri-
metritis and cellulitis, disease of a tube or an ovary, must be
treated before impregnation occurs. If, however, in spite of
every precaution, the signs of threatened abortion manifest them-
selves, the treatment resolves itself into : ( i ) The treatment of
threatened abortion ; (2) the treatment, if necessary, of inevitable
abortion : nnd (^l the treatment of t!ic wont.in post abcrturn.

The Treatment of Threatened Abortion. — The two main
principles of the treatment adopted to avert a, tkreatcned abor-
■ See note by Hanil la

ABORTION, MISCARRIAGE, AND PREMATURE LABOR. 255

tion should be perfect rest and the administration of drugs that
diminish nervous sensibility and weaken muscular action. The
first can only be secured in bed in a perfectly supine position.
The room should be darkened and kept quiet, that the rest may
be mental as well as physical. The second object of the
treatment is accomplished by giving opium, bromid of potas-
sium, and chloral. Opium enjoys a well -deserved reputation
in these cases ; many instances might be cited of its beneficent
working. It may be administered by the mouth as laudanum,
hypodermatically as morphin, or, best, by the rectum as extract
of opium in suppositories. Women on the verge of abortion
display usually a remarkable tolerance of opium, and to be effec-
tive the dose must often be large. As much as a dram (3.9 gm.)
or more of laudanum has been given within twenty-four hours
without ill effect, but, of course, the patient must in such cases
be carefully observed. With the opium it is often of advantage
to combine moderate doses of chloral and bromid of potassium.
Viburnum prunifolium^ has of late years been much vaunted as
almost a specific in the prevention of abortion, and its use has
become very general throughout this country. The verdict in
regard to this drug is, on the whole, favorable. Lusk speaks
well of it ; in England it has been tried by Campbell ^ and
Napier,^ who both recommend it ; and its employment seems to
have spread even to Russia.^ It may be given in the form of a
fluid extract, in teaspoonful doses ^ three times a day. My
routine medicinal treatment is a suppository of a grain (0.065
gm.) of the extract of opium morning and evening, and a dram
(3.75 c.c.) of the fluid extract of viburnum three times a day.

Treatment of Inevitable Abortion. — As soon as all hope
of arresting the abortion is destroyed b}' tlic appearance of signs
pointing to the unavoidable expulsion of the uterine contents, the
treatment must be radically altered. Absolute rest is no longer
necessary, while the administration of drugs that diminish sensi-
bility and weaken muscular action is positively harmful, for it
prolongs a process which in the interests of the patient were best
completed as speedily as possible. But in many cases the woman
will linger on, perhaps for days, before the greater part of the
uterine contents is expelled, and it may be weeks before she is
rid of the thickened decidua, which usually remains behind, or

* Jenks, ** Viburnum Prunifolium," "Trans. Anier. Gyn. Society," vol. i, p. 130.
» •« British Med. Jour.,'» 1886, i, p. 391. » Jbid., p. 489.

♦ Reference in " Index Med. ," 1887, Lvov.

^ Negri has recommended large doses of asafetida in cases where there had
^ been a tendency to abort or to give birth to dead children. Great
iaimed for this drug, but it has not yet been given a suthcient trial to war
of opinion in regard to it.

2S6 PREGNANCY.

of the adherent placenta, which is often retained in the uterus
after the escape of the embryo and the remainder of the ovum ;
and all this time there may be recurring hemorrhages of an
alarming character or a constant dribbling of blood, and the
lochial discharge becomes abundant, and is probably foul-
smelling. In such a case the question naturally arises as to the
advisability of interference to clean the uterine cavity thor-
oughly of substances that might give rise to future trouble.
This question receives different answers from authorities equally
entitled to respectful attention.

If the hemorrhage is severe before the os is at all dilated or
any portion of the ovum is discharged, there is no difference of
opinion as to the necessity of controlling the bleeding. This is
best effected by a vaginal tampon of sterile or iodoform gauze.
A Sims speculum facilitates the introduction of the tampon.

The vaginal tampon should be removed after twelve or twenty-
four hours, and replaced by a fresh one if necessary ; but often
as the first tampon is removed, the ovum or fetus comes with it
and the immediate symptoms may in great part subside. But
the uterus may not yet be empty ; in the early months the large
mass of deciduous membrane has almost entirely remained
behind in the uterine cavity ; later, the placenta is frequently
retained. Whether now to treat the case expectantly until
serious symptoms develop, or to remove at once the substances
in the uterus which may give rise to future complications, is a
problem that must frequently confront every practitioner. In the
hands of a general practitioner without special knowledge of
gynecological tcchnic, the best results would probably be se-
cured by the expectant treatment, so long as there was no fever,
no excessive hemorrhage, or no odor of putrefaction to the dis-
charge. In the hands of a trained gynecologist the best and
safest treatment of an abortion is an aseptic curetment.

Expectant Treatment. — When an abortion becomes inevitable,
ergot may be substituted for the drugs that have been em-
ployed to inhibit muscular action ; if there is much bleeding,
tampons are to be used in the manner already indicated, and re-
moved from time to time until the ovum is expelled, or else so
well separated from the uterine wall that it may be gently ex-
pressed or easily extracted by the fingers. The greatest care
must be exercised to avoid rupture of the membranes, for this
will probably lead to the retention of a portion of the ovum,
whereas the expulsion of the ovum en bloc is particularly de-
sirable in cases managed after this fashion. If a part of the
embryo or its appendages should remain behind in the uterus,
the woman is to be kept quiet in bed, small doses of ergot are

ABORTION, MISCARRIAGE, AND PREMATURE LABOR. 25/

to be administered, and the vagina and, if possible, the uterine
cavity are to be kept aseptic by injections of some effective
germicide, preferably bichlorid of mercury in solution. If, in
spite of every precaution, the discharge becomes foul, if the tem-
perature rises, or if hemorrhages occur, the uterine cavity must
be cleaned out. The manner of doing this will be indicated
later.

Active Treatment. — The first step of this plan of treatment
resembles that already described. The tampon is used to con-
trol bleeding, and as soon as the dilatation of the os is suffi-
ciently advanced to admit a finger efforts are made, in early abor-
tions, to turn out the ovum by sweeping the fingers around it,
and then extracting it with the finger crooked behind it like a
hook ; or Hoennig's method of expression may be tried. ^ The
ovum being wholly or in part expelled, evcr^^thing left behind in
the uterine cavity, whether thickened decidua or placental tissue,
is to be extracted. Various means have been proposed for ac-
complishing this purpose. For an adherent placenta nothing is
better, in the writer's opinion, than the finger, which can be made
to reach the fundus, the patient being anesthetized if necessary,
by pressing the uterus down from above through the abdominal
walls. By the finger the placenta is peeled off from the uterine
w-all, and afterward easily extracted. So much force is often
necessary to do this that the use of an unyielding and insensible
instrument is not advisable. To clear out the thickened decidua,
which almost invariably remains behind in early abortions, noth-
ing is so good as a curet. Diihrssen has demonstrated that
the decidua removed from the uterus in this manner is not rudely
torn off, but is separated in a natural manner in the cellular layer.
A very valuable and, indeed, indispensable adjuvant to the curet
is Emmet's curetment forceps, used as a placental forceps. If
the OS is so retracted that neither a finger nor an instrument can
be introduced, the introduction of Hegar's graduated cervical
dilators or the use of branched dilators will obviate the difficulty.

After the uterine cavity is evacuated, it should be washed
out by an intra-uterine injection. ^

The After-treatment of Abortion. — If an active treatment has
been pursued, the after-treatment will be very simple, for the
lochial discharge in these cases is slight and the involution of
the uterus rapid. Until this latter condition is perfected the
woman, of course, should be confined to bed. It is never safe,

^ The uterus is squeezed between the fingers in a combined examination, and
the uterine contents are pressed out as one would express a stone from a cherry.

2 I have tried every model of a two-way uterine catheter on the market and find
Fritsch's modification of 13ozeman*s by far the best.

2S8 PREGNANCY,

even in the earliest cases, to allow her to get up in less than a
week or ten days. The after-treatment when an expectant plan
has been pursued has already been indicated. Should septicemia
develop, it is to be managed on the same principles that govern
the treatment of this condition after delivery at term.

Missed Abortion. — By this term is meant the death of the
embryo, threatened abortion, the subsidence of symptoms, and the
retention of the ovum for a varying length of time — occasionally
very great — /// utcro, I was called in consultation to see a young
woman who discharged at term an ovum about the size of a lemon
retained /// utcro some seven months after the death of the embryo.
The young wife and her husband were wealthy and heartily wel-
comed the prospect of a child and heir. They had provided an
elaborate and expensive outfit for the baby, even including a
coach. Finally, at the end of nine months from the date of the
last normal menstruation, labor-pains appeared. The family
physician made repeated examinations and assured the husband
and wife that the progress was satisfactor}^ At length, after
twenty-four hours of hard pains, a little two-month ovum was
expelled, to the inexpressible astonishment of the parents and
the chagrin of the doctor.

Miscarriage. — Much that has been said of abortion is applic-
able to miscarriage as well ; but by the time pregnancy has
reached a period from the fourth to the seventh month it is not
likely that the condition will be overlooked, so that one great
difficulty in the diagnosis of abortion, the doubt as to the exist-
ence of pregnancy, docs not, as a rule, obtain in cases of mis-
carriage. In these cases, too, it is easier to detect the two acci-
dents which make the expulsion of the ovum almost inevitable —
rupture of the membranes and the death of the fetus ; for the
liquor amnii has reached such a quantity that its escape would
almost always attract attention, while the death of the fetus, fol-
lowed by a cessation of fetal movements and of growth in the
uterus, by a disappearance of the reflex and psychical disturb-
ances characteristic of pregnancy, and also, perhaps, by the ap-
pearance of the milk-secretion, is not likely to pass unnoticed.
The pain associated with miscarriage is greater than in abortion,
and assumes the type of labor-])ains. During the periodic con-
tractions of the uterus the organ can be felt through the abdom-
inal walls, becoming hard and firm and relaxing again as the
pain passes off The expulsion of the ovum resembles also a
labor at term, as the fetus usual 1\' is first expelled and the mem-
branes and placenta follow after. As pregnancy advances this
sequence becomes more and more the rule, but occasionally the
ovum is cast off entire, even at a late period of pregnancy. I

EXTRA-UTERINE PREGNANCY. 259

have seen such ah occurrence at the seventh month, and it has
actually been reported to have occurred at term.

Miscarriage is chiefly distinguished from abortion by the for-
mation of the placenta, and from premature labor by the fact that
this organ is quite adherent to the uterine wall, and often fails to
become detached after the expulsion of the fetus, remaining
wholly or in part adherent to the uterus, preventing proper con-
traction of the uterine muscle, and consequently giving rise to
serious hemorrhages, and, by its putrefaction, to infection.

EXTRA-UTERINE PREGNANCY.

By extra-uterine or ectopic pregnancy is meant the develop-
ment of an impregnated ovum outside of the uterine cavity. The
condition was described by Riolanus, Benedict Vassal (1669),
and by Regnier dc Graaf Abdominal sections for extra-uterine
pregnancies were performed by Nufer ( 1 500) and by Dirlewang
(1549). Bohmer (1752) differentiated the tubal, ovarian, and
abdominal forms of ectopic gestation. Schmidt (1801) described
interstitial pregnancy.

Frequency. — The exact proportion of extra-uterine to intra-
uterine gestations is difficult to determine. It has been said to
be about i in 500 normal pregnancies. Winckel, however, saw
but 16 cases in 22,000 births, and Bandl, in Vienna, but 3 out of
60,000. In the larger cities of this country a considerable num-
ber occur annually. I have operated on nine patients for extra-
uterine pregnancy in a single winter.

Classification Based upon the Situation of the Developing:
Ovum.

TUBAU

Tubo-uterine, or interstitial. The ovum develops in that
portion of the tube which runs through the uterine wall.

Tubal proper.

Tubo-ovarian. The ovum is attached to the ovarian fim-
bria.
Ovarian. The ovum develops in a Graafian foUicle.
Abdominal. In primary abdominal pregnancy the ovum at-
taches itself to the peritoneal investment of the uterus, the

broad ligament, or the intestines.
Secondary abdominal.

Ovario-abdominal. The ovum, beginning its growth in the
ovary, pushes its way out into the abdominal cavity.

Tubo-abdominal. The ovum, at first contained in the tube,
escapes into the abdominal cavity by rupture or by a
gradual separation of the fibers in the tubal coat. There

26o

PREGNANCY.

is a form of tubal pregnancy often called secondary ab-
dominal or tubo-abdominal, in which the ovum grows
downvvard and backward behind the peritoneum. This
should be known as a broad-Hgament or retroperitoneal
pregnancy.
Utero-abdominal, The ovum grows at first in the uterine
cavity, but, in consequence of a spontaneous rupture or
separation of an old scar in the uterine wall, becomes an
abdominal pregnancy, retaining its connection with the
uterus by the placenta.
Etiology. — The causes of ectopic gestation are obscure.
Any disease uf the mucous membrane of the tube depriving its
cells of their cilia, forming mucous polypi or otherwise obstruct-

I57.-Iiifv

il (Hennig).

ing its caliber, predisposes to an arrest of the impregnated ovum
in its passage to the womb. So does any condition interfering
with the normal peristat.sis of the tube. CJironic salpingitis,
therefore, is often found associated with and preceding tubal
pregnancy.

reritoneaj adhesions constricting or distorting the tubes and
congenital narrowness of tJieir caliber may also obstruct the
tubal canal.s. A diverticulum in the tube, an accessory tubal
canal, external t ran. emigration of the ovum, accessory abdominal
ostia, and atresia of tlie tube have been noted in connection with
ectopic gestation.

Clinical History. — In each of the situations noted above the
course of gii.station may be somewhat different, and each may
present an individual clinical picture on account of the difference
in the surrounding anatomical structures which are involved.
The general presumptive .signs of pregnancy are commonly the

EXTRA-UTERINE PREGNANCY.

261

same as in intra-iiterine gestation, but there is usually severe
pain. Extra- uterine pregnancy occurs often est between the
twentieth and thirtieth years. The youngest woman affected
was fourteen, the oldest forty-seven years of age.

Changes In Uterus and Vagina. — In all the forms these
changes are rather constant. Most of the alterations character-
istic of intra-uterine pregnancy are found : hypertrophy of the
vaginal mucous membrane, with increased blood-supply (purple
tinge) and increased secretion ; a soft cervix and a patulous os ;
an enlarged uterus, and, in the vast majority of cases, a develop-
ment of a deciduous membrane,
undergoing the same change as
in intra-uterine gestation pre-
paratorj' to its separation and
extrusion, which occurs in extra-
uterine gestation usually be-
tween the eighth and twelfth
week, the membrane being ex-
pelled as a complete cast of the
uterus and even of the tubes,
or in shreds. The usual clinical
history of ectopic gestation is
absence of menstruation until the
death of the embryo or rupture
of the sac, when the menses
return with the discharge of
the decidua. The metrorrhagia
which thus begins may continue
for a long time.

The other changes in the
maternal organism may varj-
with the situation of the develop-
ing ovum.

Clinical History and Pathology of Tubal Pregnancy

Usually the woman has had children, but a long time has
elapsed since the birth of the last child. The most frequent
situation of an extra-uterine gestation is the outer third of the
tube (the ampulla'). In this position it may grow upward into
the abdominal cavity, di.stcnding the tube-walls to the point of
rupture, or it may grow downward between the layers of the
broad ligament, and then backward and upward behind the
po.sterior parietal layer of the peritoneum (broad -ligament gesta-
tion). The tubal walls grow thicker from the development of

' M»rtm's .tlatiiiics of 55 cases of cxtrB-ulerine pr^nancy gii'e ihia situalion

Fij;. 158.— Decidual <
iiiincy (Zweifd).

262 PREGNANCY,

their muscle-fibers, except at spots, especially on the upper and
posterior surfaces, where rupture may occur, the woman experi-
encing severe cramp-like pain, followed by symptoms of pro-
found shock and death from hemorrhage, perhaps, in a few hours.
Fever is often seen, sometimes to a high degree, even before
rupture occurs. The usual temperature before rupture is between
99° and ioo° F. Exceptionally, the tubal gestation may proceed
to full term (six per cent, of tubal pregnancies (Winckel)). In
these cases the ovule has probably at first grown downward and
backward. If rupture occurs, it usually takes place between the
eighth and twelfth weeks, but it may be seen as early as the
fourteenth day,^ or after the sixth month. If the tube ruptures
upon the upper or posterior aspect of the sac, the sac-contents
are extruded into the peritoneal cavity with an intra-peritoneal
hemorrhage. If rupture occurs on the lower aspect, the contents
of the ovum and the blood find their way between the layers of
the broad ligament and pelvic fascia, giving rise to an extraperi-
toneal hematocele. The first variety is usually fatal ; the last is
not always directly dangerous to life, but the layers of the broad
ligament may rupture when distended with blood, and the bleed-
ing then becomes intraperitoneal and unlimited. The bleeding
may also be limited by peritoneal adhesions shutting off the peri-
toneal cavity and forming a closed sac in the iliac region. From
adhesions to intestines, complications, such as perforation and
obstruction of the bowel, may occur.

The mucous membrane of the tube undergoes a change,
being converted into a decidua as in the uterus, but there are in
the tube connective-tissue bundles between the decidual cells ;
the layers of the decidua are not well differentiated, and in
the deepest layer muscle-fibers, connective-tissue bundles, and
decidual cells are intermingled. It has been asserted by many
observers that there is no decidua refiexa in tubal pregnancies,
but Winckel has demonstrated it twice. The plications of the
tubal mucous membrane are unfolded as the tube expands.

There may be multiple (twin and triplet^) extra-uterine gesta-
tion ; coincident intra- and extra-uterine pregnancy ; pregnancy
first in one tube and then in the other ; simultaneous pregnancies
in both tubes ; or two successive pregnancies in the same tube. ^

1 Ross, *'Am. Jour. Obstet.," October, 1895. According to Hecker's statistics
of 45 cases rupture occurred 26 limes in the first two months, II times in the third,
7 in the fourth, and once in the fifth.

2 Sanger, " Centralbl. f Cyn.," No. 7, 1893.

» Coe, '*X. V. Med. Record," May 27, 1893 ; Borland, " Repeated Extra-
uterine Pregnancy," " Anier. Jour. Oljstetrics," April, 1898; Royster, *' Combined
Intra- and Extrauterine Pregnancy at Term," ihiii.^ 1897, vol. xxxvi, p. 820;
Mosely, ihid.^ 1S96, thirty-eight cases of intra- and extra-uterine pregnancy.

EXTRA-UTEJilXE PREGNANCY. 263

'■'■i!- '59-— \ ni[ilurcl Imad ligumenl luegnimc)'.

Fig. 160. — Kuplureri liroii<l Jig.iiiieiit pregnancy.

Kg. I6l.— Roplured broi

264 PREGNANCY.

Hydramnios was noted in one case of tubal pregnancy' and a
thoracopagus was found in another.^

Clinical History of Interstitial Prej^nancy. — In these cases
the ovum develops in the uterine wall, the inner side of the sac

often projecting into the uterine cavity, and having on its outer
side the round ligament and the whole length of the tube. The
usual termination of this kind of ectopic gestation is rupture into
the peritoneal cavity, Hecker collected twenty-six cases, all end-

\''z. 163.

pri^giiancy. Sac rujiiumi.

ing in rupture before tlie sixth month. Rupture into the uterine
cavity and expulsion of the fetus through the cervix arc possible.
Rupture into or growth between the layers of the broad liga-
Lment is also possible.

"■* utl, S. 37- '"CBntniibl, f. Gyn.." 1894, p. 833.

EXTRA-UTERINE PREGNANCY. 265

Clinical History of Tutx>-ovarian Pres^nancy. — The ovum
develops between the fimbriae of the tube and the ovary. The sac
may rupture with the usual consequences of such accident. It is
p)ossible, however, to sec a development of the fetus to maturity.
The ovum may lodge upon the ovarian fimbria and may thence
grow inward between the layers of the broad ligament.

Clinical History of Ovarian Pre^^nancy. — The ovum, im-
pregnated while it is still within the Graafian follicle, reaches
some degree of growth and development within the ovary. The
condition is exceedingly rare, but there are a few indubitable
cases on record.^ One case in Philadelphia, reported by Dr.
Baer, went to term. Miiller and Widerstein have reported cases of
the prolapse of a pregnant ovary into the inguinal ring and canal.

Clinical History of Abdominal Pre^^nancy. — Primary ab-
dominal pregnancy is exceedingly rare. Many gynecologists
deny its occurrence, but there have been a few authentic cases. ^
The conditions in the free abdominal cavity favor the progress of
pregnancy to the mature development of fetus. The peritoneum is
converted into dccidua-like membrane wherever the ovum comes
in contact with it, and from this source the chorion and placenta
derive nutriment. The ovum is surrounded by a fibrous and vas-
cular capsule. In abdominal and in advanced tubal gestation
abortive labor-pains appear at term. The cliild dies at or shortly
after this period, and the liquor amnii is absorbed after the death
of the fetus. The abdomen is consequently reduced in size and
the tumor is changed in consistency. The fetus may be con-
verted into a litliopcdion and may remain as an innocuous tumor
in the abdomen for years (see Termination of Extra-uterine
Pregnancy, and Changes in Fetal Body after Death). The child
is likely to be small and ill-formed, but occasionally over-
grown children are reported, no doubt on account of an existence
of the fetus prolonged beyond the usual duration of pregnancy.
In advanced cases of abdominal pregnancy the fetal movements
are exceedingly painful to the mother. Abdominal pregnancies
may end in rupture of the sac or there may be profuse hemor-
rhage into the sac-cavit}'.

Clinical History and Patholoj^y of Utero-abdominal Preg-
nancy.— This condition is very rare. The pregnancy is at first

^ Cases are reported by Poienko, Werth, Paltauf, Leopold, and Martin. See
Winckel, **GeburtshUlfe " ; Kelly, article in "American Text-book of Obstetrics. "

* Schlechtendahl has reported a case of primary abdominal pregnancy in which
a fetus fifteen centimeters long was found incapsulated near the spleen. The tubes and
uterus were normal (*♦ Frauenarzt," 1887, ii, pp. 8l-86). Braun's and Zweifcl's
cases (" Archiv f. Gyn.," Bd. xli, H. i and 2), in which the placenta was attached
to the posterior uterine wall and to the sigmoid flexure, and Koberle's case, in which
impregnation occurred through a vagino- abdominal fistula after hysterectomy, were
unquestionably, to my mind, primary abdominal pregnancies.

PRF-GlfAXCY.

EXTRAUTERINE PREGNANCY, 267

intra-uterine, but the ovum escapes into the abdominal cavity
through an opening in the uterine wall, retaining a connection
by the placenta with the uterine cavity. The process of extru-
sion must be gradual. These cases follow either a Cesarean
section or a rupture of the uterus at a previous labor. The
fetus may grow to full term.^

Terminations of Extra-uterine Pre^^nancy. — Death and Ab-
sorption of the Young Embryo zuith Absorption of the Liquor Amnii,
and Atrophy of tlie Gestation Cyst, — Of all the terminations of
ectopic gestation, this is the most favorable. It is exceptional,
and should never be counted on in practice. The embryo must
die before the second month to be completely absorbed. At the
best, chronic salpingitis with adhesions persists, and the woman
may, therefore, be left a chronic invalid.

Rupture of the sac and profise hemorrhage occur most com-
monly in tubal gestation, when the growth is upward toward
the abdominal cavity. At least two-thirds of all ectopic gesta-
tions end in rupture of the sac. The rupture may occur when
the ovule grows downward between layers of broad ligament ;
also in tubo-uterine, tubo-ovarian, ovarian, and abdominal preg-
nancies. The accident commonly destroys the embryo, which
may escape into the abdominal cavity. Up to the second month
the extruded embryo may be absorbed. Later, it may be found
lodged among the intestines, perhaps far removed from the pel-
vic organs and usually surrounded by clotted blood. ^ The hem-
orrhage may be fatal in as short a time as two hours ; it usually
takes from eight to sixteen hours, however, for the woman to
bleed to death, and perhaps longer. The hemorrhage may be
fatal as late as the second, third, or fourth day, or there may be
successive hemorrhages, perhaps days apart, until the patient is
gradually exhausted or is suddenly destroyed by an unusually
profuse outpour of blood. Surprisingly small tubal gestation sacs
may, on rupture, give rise to fatal hemorrhage. The determining
cause of rupture is not always apparent. It may occur while the
patient is lying quietly in bed, but may follow the straining of defe-
cation or urination, coitus, a blow upon the abdomen, a gynecolog-
ical examination, an operation like curetment, or any sudden
physical effort or mental excitement. The rupture may be due

* " Ausgetragene secundSre Alxlominalschwangerschaft nach Ruptura uteri, im
vierten Monat," Leopold, *' Archiv f. Gyn.," lii, 2, 376. Fullerton, ** Annals of
Gyn!," October, 1 891.

* Burford reports an extraordinary case in which the tul)e ruptured, the fetus was
extruded through the rent, the cord was torn across, and the fetus with the cord
attached was found in the abdominal cavity inclosejd in an adventitious sac. The pla-
centa remained in the tube and the rent in the latter, through which the fetus escaped,
had healed. •* Brit. Gyn. Jour.," 1892.

PRECXAATY.

Rfi. 167.— Rupturfd tubal iircgii-iiL} ; sac involTing the L=Lhi

to contraction of the tube-walls, to menstrual congestion, or to
the steady growth of the tumor. Rupture of the sac or of a
blood-vessel in its wall, with profuse hemorrhage, has occurred
long after the destruction of the cmbr)-o and cessation of f;roftth
in the sac (two years in ont- cast-).

Kig. 168.— Kuplun.-.

' t'lBs- '59 '0 '6' a'i'l '67 10 17(1 inclusive, alio figs. 163 to ifij.arc froin phola-
(^jihs preieiilcd lo me by the I^C Dr. Fonnsil, Sot some lime coroner's phyucinn
iif Philadelphia. He obliined Ibe specimens in his official cagncily, while invMEl-
gxling the cause of sudden deaths.

KX7-K.UC-TERIJ^E FRECNA.VCY. 269

Fig. i6g. — Rupmteii luhul [in;)jn:inLj ; sat imolviiig ihe ai

Fig. 170,— Ru|Jtured lubfl! ].iregLi«iici( ; sac silUBittl Hliolly in tlic islhmus. The
liie of ibe sac Is rcry amalt [□ occn»ion, on niplurc, a faul hemorrliage : lis silualion,
however, near llie uI'tus, is a very dangermia ot"-.

',. 171. — Ku|ilurcU lubal iirr^iiuiity ; lac occupying the niiddlc ihini iti the lube.

PREGMANCY.

EXTRA-UTERINE PREGNANCY. 2/1

Rupture of sac with extrusion of its contents^ and interstitial
hemorrhage iftto the sac-walls^ without escape of blood into peri-
toneal cavity or between the layers of broad ligament, was the
termination of one case of tubal gestation under my observation.
This occurrence might well be followed by atrophy of the ovum
and sac.

Tubal moles are frequently seen as the result of an old tubal
pregnancy ; the ovum is infiltrated and surrounded by blood,
clotted and often organized. The tubal walls are also infiltrated
with blood and are much thickened. The whole mass constitutes
a solid tumor of the tube in which the embryo may not be found,
and atrophied chorion villi in small numbers are only discovered
after a careful microscopic search.

Grozuth of the Fetus after Third Month ; Its Death at or before
Maturity and the Changes that Occur Aftenuard. — A continued de-
velopment of the fetus in the later months of pregnancy is
seen most often in abdominal or in tubo-ovarian pregnancies,
though it is possible in the tubal gestation with retroperitoneal
growth (broad-ligament pregnancy). The fetus after death
may be converted into a lithopedion or may be mummified, and
in these conditions may remain in the abdominal cavity indefi-
nitely (in Sappey's case fifty-six years), or may be removed by
operation through the abdomen, vaginal vault, or possibly by
the rectum. The soft parts may macerate and may be absorbed,
leaving the bones, which remain as an innocuous abdominal
tumor or ulcerate into the bladder, intestines, or through the
anterior abdominal wall. Ulceration into the bladder is a par-
ticularly unfortunate complication. I have seen an old lady die
of peritonitis caused by the ulceration of a parietal bone through
the transverse colon. Her history indicated an abdominal preg-
nancy having its origin many years before.

The fetal body may putrefy from the contiguity of the intes-
tines and their contained micro-organisms and the consequent
access of bacteria to the highly putrescible sac-contents. In the
same way the gestation -sac is converted into an abscess.

Terminations of Ovarian Pregnancy, — There may be an ar-
rest in the development of the ovum at an early period. In
one case the small, cystic, ovarian tumor containing the fetal
bones was retained in the abdomen for years. In another
case the fetus went on to full development, then died, and
was removed in a good state of preserv^ation at least one year
later. Rupture of the sac and profuse hemorrhage may occur.

In tubO'Uterine or interstitial pregnancies the ovum and em-
bryo may be discharged into the uterine cavity, and may be
evacuated by the natural passages. There are at least two such

272

PKEG>VANCy.

cases well authenticated. Rupture of the sac and hemorrhage
into the peritoneal cavity is, however, the rule. In Mascka's case
the head of the fetus passed into the abdominal, the breech into
the uterine, cavity.

in cases of so-called liiBal abortimi (so named by Werth)
thtrc is an internal rupture of the tubal wall or of its connection

.70.-

with the ovum, and blood is poured through the fimbriated
extremity of the tube into the abdominal cavity. The blood
clots filling the pelvis in such a case may have a peculiar sausage-
like form imnnrted to them by the tubal canal. The whole ovum
Kied through ihe abdominal orifice of the
w^i<;h the fimbriated extremity was

EXTRA-UTERIXE rREGNANCY.

273

closed by inflammatory adhesions the outer end of the tube was
converted into a hematoma.

It is possible that a tubal pregnancy may rupture in its early
stages, the embryo be expelled into the abdominal cavity, retain-
ing its connection with the tube by the cord and placenta, and
the fetus thus continue to further or to full development. This
is called a j(ri?«(/(j;;f or tnbo-abdominal pregnancy.^ Rupture in
cases apparently of this character may not have occurred.
There may have been a retroperitoneal growth of the ovum and
an enormous dilatat'on of the tubal walls.

Grou'lh and dci<clop»H-nt of the filaccnla after fetal death has
been described, but has not yet been demonstrated beyond

Fig- 177. — Dingraio sli w ir | ^lvn. li
is cro*,ledforv.ar<l Willi ihc Un I kr Id.iiil
is oiniiressed behind against iht. aacrum (Skeae)

doubt. It would seem impossible arguing from the behavior of
the placenta in uttio after fetal death

Pi'ofuse htmetrrkagi into tlu ^tstation sac, forming a large
hematoma, occurred in one case under my observation.

Hematoceles and liemalomata in the abdomen, pchts, and pelvic
eonntctive tissue in one-third or more of the cases are due to the
hemorrhage from a ruptured gestation sac. The blood may
collect in front of the uterus (ante-uterine hematocele), more

ruplure of Ihe

274

PREGNANCY.

commonly behind the uterus (retro -uterine heniatoccle), may be
encapsulated in the neighborhood of either broad ligament, or
may be contained in the pelvic connective tissue on either side
of the uterus. These accumulations of blood may suppurate, and
may thus prove fatal. They may be evacuated through the abdo-
men or often through the vaginal vault. If not too large, they
are absorbed.

Symptoms of Extra-uterine Gestation. — The Subjective
Signs. — In the early weeks ur months the subjective .signs nf
ectopic pregnancy may be indistinguishable from tliose of normal

Fig. 178, — Diagiam «{ iiiir.i[icriioiii:nl rufiiurc of tubftl pregnincy. Free lilwJd
in Douglas' cul-de-sac, and among ihe intestines: S, Sj'mplij'iis ; K, reclum
(Dickinson).

intra-uterine gestation. In the tubal variety, which is by far the
commonest, theic may be no indication of any abnormality
until rupture occurs. In the vast majority of cases, however,
rupture is preceded by severe cramp-like pains, usually in one
or the other ihac region, often accompanied or followed by the
discharge of deciduous membrane.

The pain of cxtra-utcrine pregnancy is its most distinctive
symptom- It may be defined as a pain de.scrJbod by the patient
in st^or^o»•«^ tcmis ; occurring in paroxysms, with intervals free
aring at any time from a few days to months

EXTRA-UTERINE PREGNANCY.

275

after a normal menstruation ; situated often in one groin, though
frequently indefinitely referred to the lower abdomen ; extending
down one leg or up to the epigastrium ; and a pain so severe as
to occasion profound systemic disturbance — ^syncope, followed
by nausea and vomiting, a cold sweat, hysterical outbreaks,
complete disability, and every appearance of excessive shock.
The temperature is almost always slightly elevated. There
may be high fever, and the general health may be much im-
paired. When advanced development occurs, as in abdominal
and in some cases of tubal gestation, no symptoms may arise
until the time for labor has passed, when pain and other com-
plications, due to the pecuHar character of the abdominal tumor,
may appear. There is usually cessation of menstruation for
one or two periods ; then a return of the flow as an irregular
bleeding, which may last for months. In some cases irregular
bleedings begin with conception and last until rupture — there is
no cessation of menstruation. In others one period is slightly
delayed ; those after and before are normal. Again, the delayed
period may be unnatural in character. In exceptional cases the
menstruation occurs at the normal time, but is more profuse or
scantier than normal. The subjoined table, made up from my
case-books, shows the hienstrual history in twenty-three cases
of which I have records :

Crssation of

RKTrRN OF Flow.

CONTINL-ANCK.

Discharge of

Menses.

None.

Dkcidla.

For two months.

None.

I'aticnt died from ruplurf in a few hours at

second month.

For thirty-eight

In thirty eight da)s.

Lasted t w e n t y-

None.

days.

seven da vs.

None.

Menstruation rejj-

One period con-

None.

ular, except that

tinued a month.

one periotl con

the flow j)ersist-

tinned a month.

ing at time of
operation.

None.

Regularly every

The normal length

None.

month ; no cessa-

of time three to

tion of menstrua-

five days ; fetus.

tion.

two and one-half
months, removed
at time of ojh.* ra-
tion.

For thirty-eight

On thirty-eighth

None.

At the appearance

days.

day ; did not re-

of the delayed

api^ar at time for

menstruation.

next period.

None ; a flow of

In two weeks after | Two days.

At the fifth week

blood occurred

discharge noted

after last normal

three weeks after

in preceding col-

menstruation ; in

last normal pe-

umn.

the second flow of

riod.

blood.

2/6

PREGNANCY,

Cessation of
Menses

Return of Flow.

Two and one-half In two and one-half
months. ' months.

None.

For eight weeks.
For fifty-three days.

None.

Missed two periods.

Missed one pericHl ;
returned ten
days late.

Two weeks after
last normal pe-
riod.

In eight weeks.

In fifty-three days.
(At preceding
menstrual period
there had been
a few drops of
blood. )

In four weeks.

In two and one-half
months.

In thirty -eight days.

F'or three lunar

None.

months.

Twelve days late ;

In twelve days ;

cessation of men-

then in eleven

ses for fortv (lavs

(lays, and again

from last normal

in a lunar month.

period.

Three weeks late.

In seven weeks;

aj^ain in a week ;

a<jain in three

weeks ; again in

a week.

None; a fl o w

Continued for a

appeared fifteen

month.

days after cessa-
tion of last nor-
mal sickness.
For six weeks ; two
weeks late.

For seven weeks ;
three weeks late.

For two calendar
months.

\\\ six weeks ; attain
in seven weeks.

In seven weeks ;
again in four
weeks ; again in
forty days.

In two months.

Continuance.

For three weeks.

Discharge of
Decidua.

For two weeks.

For four months.
For two weeks.

None ; rupture oc-
curred at third
raunth ; death in
seven hours.

None.

At the third month.

For six weeks.
Twelve days.

None.

On third or fourth

day of flow.
None.

Lasted one day ;

returned in ten

days; slight dis-
charge for three

weeks, then a

more profuse flow

lasting almost

continuously for

three and one -half

months.
Rupture occurred with profuse internal

bleeding ; no discharge until tive days

after operation, three an<i one-half

months after cessation of menses.
Lasted one day ; On the first day of

then two days; third reappear-

and on third re- ance.

appearance, three

weeks.
No long-continued On the third day of

flow.

first
flow.

Non:^.

return of

For a week ; dis- None.
charge continuing
at time of opera-
tion.

Last men.strual dis- ' On the first day of
charge continued | the first return of

a week and was
very profuse.
Lasted three weeks.

the flow.

On the first day of
return of flow.

EXTRA-UTERINE PREGNANCY.

277

Cessation of

Return of Flow.

Continuance.

Discharge of

Mensks.

Decidua.

Two and one-half

In two and one-half

Six weeks.

After four weeks of

months.

continuous flow.

Missed three pe-

Three months and

Six weeks.

On second or third

riods.

three weeks.

day of flow.

Missed two periods.

None.

Decidua discharged
on the day of the
operation, sixty-
two days after
last menstruation.
Even with the dis-
charge of the de-
cidua, there was
no bleeding.

Other symptoms noted have been irritable bladder or dys-
uria ; marked constipation or. even obstruction of the bowels if
the tumor is on the left side ; edema of the corresponding limb
and aching pain in it, especially at the groin ; or numbness and
loss of power. Pulsating vessels may be felt in the vaginal vault. ^

Objective Sig:ns. — In tubal pregnancies an exquisitely sensi-
tive tumor may be felt to one side of, behind, or possibly in front?
of the uterus, quite firmly fixed after the third or fourth week,
and doughy in consistence. The uterus is much smaller than
would be expected from the duration of the pregnancy. After
the third month ballottement may possibly be practised upon
the tubal tumor. The uterus is usually displaced forward,
backward, or to the side opposite the tumor. The decidua is
expelled from the uterus in a large proportion of cases (fifty per
cent, of my own). If the discharged membrane can be obtained,
it will present, under the microscope, unmistakable character-
istics of decidua. It may be extruded in fragments or as a com-
plete cast of the uterus.

Symptoms of Interstitial Preg^nancy. — A diagnosis is diffi-
cult or impossible. The uterus enlarges to a greater degree
than in any other variety of ectopic gestation, and it may be im-
possible to determine whether or not it is symmetrically enlarged.
The condition is recognized after an abdominal section or upon a
careful intra-uterine exploration.

^ Hofiaeier claims that the pulsation of arteries on one side of the cervix and
Mt fqpoo the other is a yaluable sign of extra-uterine pregnancy ; and, moreover, that
itismiipi of life in the ovum, ceasing when the embryo dies and the ovum stops
(powiiiff*

' For three or four weeks the tubal tumor is free ; quite suddenly it sinks into

*^p«lfil fioA its tDCreasing weight, and wherever it comes in contact with the

"*^ pnlloneitiii the latter is changed into a decidua-like structure to which the tube

278 PREGNANCY,

Atxlominal pregnancy may be recognized when the ovum
occupies Douglas' pouch, as the fetal parts may be made out
with startling distinctness through the posterior vaginal vault.
A sacculated uterus, however, might easily be mistaken for an
abdominal pregnancy.

Dias^nosis. — A diagnosis of extra-uterine pregnancy can
usually be made before rupture. I have made a positiv^e diag-
nosis in the majority of my cases, hi spite, however, of careful
attention to the patient's history and a painstaking physical ex-
amination by an expert, a diagnosis before rupture is sometimes
impossible. Usually the condition is not recognized in general
practice until rupture has occurred. At this time a history' of
early pregnancy, a paroxysm of frightful pain, sudden collapse,
symptoms of internal hemorrhage, with abdominal distention, and
a vaginal examination showing a pelvic tumor with possibly the
physical signs of effusion into peritoneal cavity make the diag-
nosis perfectly clear, and indicate an immediate celiotomy. These
symptoms have been closely simulated by rupture of a varicose
vein in the broad ligament, by rupture of an ovarian cyst or torsion
of its pedicle, and by pelvic tumors coincident with intra-uterine
pregnancy. But as all these conditions demand the same treat-
ment, a mistake in the differential diagnosis between them is of
no consequence. If the cramp-like pains of ectopic gestation
lead a patient to consult a physician ; if she give a clear histon'
of impregnation ; if she present all the earlier signs of pregnancy,
with the discharge of blood and membrane which the microscope
shows to be decidual ; if there be a very sensitive tumor in the
neighborhood of the uterus, on which ballottement may, perhaps,
be practised, and if the uterus is not so large as it should be, — the
diagnosis is justified, and the necessary treatment, also, involv-
ing, as it (\ocs^ a serious operation. Among the conditions in
the pelvis that may make the diagnosis impossible are : Abortion,
in consequence of or coincident with some growth near the
uterus ; pyosalpinx, with an indistinct or untrustworthy histor>'
of pregnancy ; intra-uterine pregnancy, with rapid development
of a fibroid on one side of the uterus ; development of an im-
pregnated ovule in one horn of a unicornate or bicomate uterus,
or on one side of a double uterus.

Prognosis. — Without surgical treatment about two-thirds of
the cases die ; one-third escape the immediate danger of death.*

^ In 265 cases without surgical intervention, 36.9 per cent, recovered, 63.10
per cent, died (Winckel's '• (ieburtshulfe," 2. Aufl., S. 254). In loo cases col-
lected by Kiwisch, the mortality was 82 per cent. ; in 132 collected by Heckcr, 42
per cent. ; in 150 by Hennig, 88 per cent. ; in 500 cases collected by Parry up to
1876 the mortality was 67.2 per cent. ; in 626 cases collected by Schauta, from 1876
to 1890, 241 ended spontaneously, 75 in recovery, and 166 in death, a mortality of
68.8 per cent. Martin states that of 585 cases operated upon, 76.6 per cent, recov-
ered ("Centralbl. f. Gyn.," No. 39, 1892).

EXTRA UTERINE PREGNANCY, 2/9

Treated by abdominal section, the mortality should be about five
per cent, or lower if the operator sees the patient in time. I have
the records of thirty-one operations performed by myself with
three deaths. Two of the fatal results were in women already
exsanguine, who died a few hours after the operation without
regaining consciousness. The other was in a chronic drunkard,
who died on the fifth day from cirrhosis of the liver. Of those
patients who do not die directly in consequence of the tubal ges-
tation a large proportion remain invalids, and many die at a
remote period from various complications, as bowel obstruction,
ulceration, suppuration, or hemorrhage.

Treatment. — As soon as the diagnosis is established with
reasonable certainty, whether the sac has ruptured or not, the re-
moval of the gestation sac by celiotomy is the only treatment
worthy of consideration. Electricity is an uncertain and unre-
liable remedy, and the recoveries ascribed to its use are the
result of nature's effort to effect a cure. Injections into and
puncture of the sac to destroy the embryo should be relegated
to the category of discarded and discredited procedures.

Abdominal section is the only reliable and trustworthy plan
of treatment. The removal of a gestation sac and the control
of hemorrhage is sometimes a difficult operation, and is not to be
undertaken rashly by an unskilled operator. In favorable cases
in which a trained nurse is kept in constant attendance, and in
which the physician can reach the patient quickly, it might be
justifiable to wait, after diagnosticating extra- uterine pregnancy
before rupture, for the death of the embryo and the atrophy of
the sac, which will occur in about one-third of the cases. As a
rule of practice, however, the only safe plan is either to operate
immediately one's self, or to refer the patient to a competent
surgeon without delay.

After rupture, the patient's only hope lies in an immediate
abdominal section, evacuation of the blood from peritoneal cavity,
the ligation of the blood-vessels supplying the sac, and its com-
plete removal.

The Teclmie of Abdominal Scctioti for Tubal Pregnancy. —
The operation is often performed in an emergency, and must,
therefpre, be hurried. Plenty of time, however, should be taken
to secure an absolutely a.septic condition of the field of operation
in the patient, of the surgeon, assistants, dressings, and imple-
ments. If possible, the patient should be transported to a well-
appointed hospital. If there has been much bleeding and the
patient's condition is bad, the anesthesia should be limited and
the operation should be finished in the fewest minutes possible. It
is possible to conclude the operation, to the last abdominal stitch, in

2 So

PKEGNANCY.

less than eleven minutes and with less than an ounce of ether.'
No attention should be paid to the blood that gushes in enormous
quantities from the abdominal cavity when the peritoneum is
incised. It has already been shed and is of no use to the patient.
The side affected should have been learned by the history,^ if not
by the physical signs. This tube should at once be grasped
between the thumb and fingers of one hand, the broad ligament
should be transfixed by a pedicle needle to the inner side of the
round hgament, and ligated at inasst:^ The tube and ovary are
then cut away. The abdominal cavity should next be flushed
with a large quantity of sterile water * and drained with both a
glass tube and gauze packing.^ For twelve or twentj--four
hours after the operation vigorous stimulation and an active
treatment for the acute anemia are necessary. The glass tube is
sucked out once a day with strictest aseptic precautions. The
gauze is removed at the end of forty-eight hours, and the glass
tube is then withdrawn after a rubber tube is slipped within it to
take its place. Through the rubber tube the pelvic cavity is irri-
gated once a day with sterile water. The irrigation is continued
for about ten days, or until the water returns perfectly clear with-
out bringing with it small snow-flake-like clots and the debris of
the deciduous formation on the peritoneum which constitutes the
adhesions between the tubal sac and surrounding intraperitoneal
structures. Ky this tcchnic in thirty-one operations I have not
lost a patient from the operation itself; there has been no fever
during convalescence ; every wound healed promptly within
three weeks, and there was not a single persistent sinus.

' This pnlienl was ill firet Irealeii by her pliyaicinn for a miscarriage— the com-
monest mistake in the dla^nusis of eKtra-uteriae pregnancy. After ruplute the true
condition wns reiogniicd. but the woman was so reduced by the internal hemorrhage
that she was prononoced a. hopeless case, and (he pbyalcian left the hinise lalt hi
night saying be would call the next tnoming to sign her dealh certilicale. To his
surprise he found her aliic. A few houis later I operated on her with success, though
she was pulseless and in as desperate a conditioti as possible,

' It is odeii impossible to tell from a physical examination which tube is in-
Toleed, Init 1 have found the history of pain down aae leg and not the other of great
Talue in dingnosticau'ng the side affected,

' It is waste of invaluable time in the niajority of cases to ligale the blood-
vessels separately.

* I linie practically given up douching tile abdominal cavity nft'r alxloniinnl
sections, eicjit in extra uterine pregnancy Thti-e i.s no other means which fia
rapidly and surely removes hlood-cloLs froni the abdomen. It is, moreover, a great
advantage to leave the large quantity of h^I water which remains in the abdominal
cavity after iirigatioO-

EXTKA-VTERIXE PKEGNAXCY,

281

The vaginal operation for tubal pregnancy in the first three
or four months is, as yot, In its infancy. It has the serious dis-
advantages that, on account of uncontrollable hemorrhage, avagi-
nal hysterectomy or hasty abdominal section may be necessary,
and if the tube is simply incised and not removed, a diseased and
useless pelvic organ is left behind to be the source of future
trouble. Moreover, as in all vaginal sections, nicety and pre-
cision of work is impossible through tlic vaginal vaults.

In interstitial pregnancy, on account of the difficulty of diag-
nosis, little can be done until rupture and hemorrhage have
occurred, when an abdominal section must be performed. The
sac should be cleared of all its contents, and its edges should be
sewed to the abdominal wall ; after the bleeding vessels are se-
cured, the sac should be drained. If this technic is impossible,
ligation of the uterine and ovarian arteries is indicated, drainage
of the sac, or possibly supravaginal amputation of the uterus.
It might be well, the diagnosis being clearly established, to try
to effect evacuation of the gestation sac into tlic uterine cavity
after thorough dilatation of the cen-ical canal. A mistaken
diagnosis, however, would lead to a premature termination of a
normal intra-uterine pregnane^'. Tait describes a case in which
he found it possible to incise the sac, turn out its contents, and
drain it, after fetal death, ^ Kngstrom treated a case successfully
by incising the uterine wall, extracting the dead fetus and its
appendages, making and enlarging an opening between the ges-
tation sac and the uterine cavity, sewing the uterine wall firmly
together, as after a Cesarean section, and closing the abdomen
without drainage.^

Ovarian pregnancy is to be treated as a tubal pregnancy, —
namely, by excision of the sac with the ovary. As a matter
of fact, the operation is undertaken in these rare cases for an
ovarian tumor, and the operator discovers, to his surprise, after
ojjening the abdomen, the contents of the ovarian cyst.

In advanced cxlra-utcrine pregnancy the operator should delay
interference until just short of term, when the fetus and. if possi-
ble, the feted sac should be enucleated and extracted whole. It
is not infrequently necessary to cut the cord off short, stitch the
sac wall to the abdominal wall, and drain the sac. Forty opera-
tions (1889-1896) after the seventh month of gestation, witli liv-
ing and viable infants, have been collected by Dr. R. P. Harris.*
In this number there were ten maternal deaths ; twenty-seven
■■•'■■"■'« "-irvived the operation. Wlun death of the fetus has
is best not to subject the woman to the danger of the
'■ Cenlralbt. f. Cyn.," No. Si ^896.

282 PREGNANCY.

several possible ultimate terminations, but to perform celiotomy
and to remove the fetus and its entire surrounding sac. If the
exsection of the sac is found to be too difficult or dangerous, it
is permissible, some weeks after fetal death, to cut the cord off
short, leaving behind the atrophied remains of the placenta.
If this is done, the sac-wall should be stitched to the abdominal
wail, and thus drained for a length of time until the placenta
comes away. Meanwhile daily irrigations are required and
antiseptic powders may be dusted in the sac-cavity. In case the
gestation sac is low down in Douglas' pouch, bulging the poste-
rior vaginal wall, vaginal section and the delivery of the fetus
by the natural passage may be considered ; but the dangers and
disadvantages of the vaginal operation should be carefully con-
sidered ; these are : Difficulty of extracting the fetus, if it is large,
uncontrollable hemorrhage, puncture of an intestine, infection of

I'ijT. 179, — Pregnancy in ihe rudimentary horn of a ulerus un(tx>Tnis, which hu
become, seciindarily, .ilidoniinal (autliiir's coUeclion, OUlelrical Museum, UniverkitT
Of rer.„.)]vi,m.i).

the general peritoneal cavity, either at the time of the operation,
or in sub.scqucnt irrigations of the sac, and adhesions involving
the utcru.s and appendages after the woman's recovery from the
operation.' Vaginal .suction is applicable in case of an old gesta-
tion sac undergoing .suppuration and containing a much macerated
or disintegrated futu.s. In some cases of intraligamentary preg-
nancy it is possible to open the sac extraperiloneally by an inci-
sion above Fouparfs ligament. It is always advisable, however.
to make a preliminary abdominal section to learn the relations
of the gestation sac.

Pregnancy in One Horn of a Uterus Bicomis or Unicornis.
— Pregnancy in an ill-developed horn of a uterus unicornis may

1 For B gomi l>il.liii,;r.ii>hy of ihe removal of exlra-ulerine fetuses through the
v«gina nmJ by ilie rectum ice J. T. Winter, '■ Am. Jour. Obstcl.," 189I, p. 34.

EXTRAUTERINE PREGNANCY. 283

exactly resemble a tubal or interstitial pregnancy, and will
probably end in rupture at the apex of the cornu. ^ This is par-
ticularly true if the impregnated ovule develops in a rudimentary
horn, in which the conditions are almost the same as in a tube,
except that rupture takes place later. On the other hand, a
pregnancy in a uterus bicornis may terminate prematurely, or
even at term, by expulsion of the product of conception through
the natural passage.

The diagnosis of pregnancy in a uterine horn is difficult or
impossible. It is mistaken, usually, for tubal gestation. The
removal of a gestation sac in a rudimentary uterine horn is
commonly easy, as a convenient pedicle is formed by the attach-
ment of the horn to the lower segment of the better-formed
half of the uterus.

Hydrorrhea Qravidarum. — A watery discharge from the
vagina of a pregnant woman may have three sources : catarrhal
endometritis, rupture of the membranes, and edema of the
uterine walls. The last is a very rare cause indeed, and I am
somewhat skeptical as to the possibility of scrum leaking from
the uterine walls, but it has apparently been operative in a few
cases. 2 In catarrhal endometritis the fluid is discharged suddenly
in considerable quantities ; it rcaccumulates and is again dis-
charged, the recurrent hydrorrhea continuing, perhaps, until
term, although usually after the second or third discharge labor
is brought on. The fluid discharged in a case of catarrhal endo-
metritis is thin mucus. In a typical case under my observation
there was a discharge of more than a pint of fluid at the seventh
month of pregnancy, while the patient was lying quietly in bed.
It was supposed that the membranes had ruptured and that labor
was imminent, but no pains appeared, and after confinement to bed
for a week the patient was allowed to get up. A month later there
was another profuse discharge, — certainly more than a pint, —
again occurring while the patient was quietly at rest in bed. Twelve
hours later labor-pains appeared ; in the latter part of the second
stage of labor the membranes ruptured and about a quart of
liquor amnii was discharged. A careful examination of the
membranes failed to detect a perforation remote from the scat of
rupture.

Rupture of the membranes and the discharge of liquor amnii
in pregnancy are commonly followed by labor-pains within thirty-

* Three cases of pregnancy in rudimentary horns are rej)orted by Turner,
Weftby and Solin (Lusk's ** Obstetrics "). Kussniaul collected thirteen cases.

* Chaian, •* Centralblatt f. Gyn.," No. 5, 1894, p. 105.

284 PREGNANCY,

six hours. It is not very unusual, however, for three or four
days to elapse from the time of rupture to the onset of labor. I
have several times seen a month intervene between the rupture
of the membranes and the beginning of labor, and in one case
under my care the membranes were perforated at four and one-
half months without inducing labor. The patient was the wife
of an English officer in India. She had been told by a skilful
Indian masseuse that she was pregnant, but an English physician
whom she consulted assured her she was not, and, to prove that
he was correct, inserted a sound into the uterine cavity. There
was immediately a gush of liquor amnii.' In spite of a journey
of some 1 500 miles from the interior to the coast, the long voy-
age from India to England, and thence to the United States,
liquor amnii flowing from the vagina at every roll of the ship or
jolt of a carriage, labor did not appear until term, four and a
half months from the time the membranes were punctured.
There was found, after delivery, a round, regular opening in the
membranes, about the caliber of a lead -pencil, midway between
the seat of rupture and the placenta, which was attached at the
fundus.

PART II.

THE PHYSIOLOGY AND MANAGEMENT OF LABOR

AND OF THE PUERPERIUM.

CHAPTER I,

Labor*

This chapter deals with an important practical subject, — the
management of a woman in labor. The questions involved in
this study confront every practitioner of medicine at some time.
Every one in possession of a medical diploma is popularly sup-
posed to possess the ability to manage a labor case, and every
one who essays the practice of medicine will have his ability
put to the proof before his medical career has run a very long
course. To a beginner in obstetric practice there is much that
is tr>'ing and embarrassing. The novel and intimate relations in
which the physician is brought with his patient ; her ver>' evident
distress and dread at the idea of being subjected to the necessary
examinations and manipulations more or less revolting to every
woman ; the doctor's keen consciousness of a lack of experience ;
a feeling of mistrust in his capacity to make the necessary diag-
nosis as to stage of labor, the presentation and position of the fetus;
the knowledge that his every movement is watched by critical
friends or attendants of the patient, who possess, perhaps, just
what he lacks, — practical experience, — all unite to produce a most
unenviable frame of mind in the practitioner attending his first few
cases of labor. Some consolation, however, can always be found
in the reflection that labor is a natural and a comparatively easy
process, in the large majority of cases ; that a physician's duty is
one mainly of inaction and non-interference, and that most prob-
ably the labor will terminate fortunately for mother and child, in
spite of his inexperience. It is evident, however, that no one
can predict what may occur in any given case. There may sud-
denly arise some accident of the gravest nature, which must be
immediately recognized and promptly treated. It is under such
circumstances that a physician's education and knowledge are

285

286 LABOR AND THE PUERPERWM,

put to the test. It is plain, therefore, that in a work on obstet-
rics it must be the writer's aim to impart the requisite knowl-
edge to cope with all sorts of dangerous emergencies. This
consideration makes it necessary to dwell at length upon all the
possible complications, accidents, and difficulties of the child-
bearing process, with the result, I am quite sure, of leaving upon
the student's mind the impression that parturition is a more dan-
gerous process than is really the case. It is well to recollect, there-
fore, that nature alone, in the majority of cases, with very little
artificial aid. is capable of terminating safely the birth of the
child ; but at the same time it should not be forgotten that at
any moment a dangerous complication may occur, which must
be immediately recognized and promptly dealt with.

It is convenient to begin the study of labor with a definition
of the process.

Labor is that natural process by which the female expels
from her uterus and vagina the ovum at its period of full
maturity, which is reached, on the average, two hundred and
eighty da)'s after the first day of the last menstruation. The
process is divided into three main stages or acts. — the expansion
of the birth-canal, the expulsion of the fetus, and the delivery
of the remainder of the ovum. This is a brief description of an
important and complex function in woman, but as one studies
the causes, the prcmonitor)^ signs, the symptoms, and the phe-
nomena of labor, it will be seen that it is comprehensive and
correct, but that it needs some amplification.

To analvzc the first declaration as to the time that labor
occurs, the intcUii^cnt student would naturally inquire why it is
that labor comes on just two hundred and eighty days, or forty
weeks, or ten lunar months from the beginning of the last men-
strual flow. This question has given rise to endless sp)eculation
in all ages of medicine, some of it very far from the truth.
Several explanati(Mis may be offered, each reasonable, and each
no doubt in part accountable for the occurrence of labor in the
majority of cases at a distinct and specific time. The p)eriod of
two hundred and eii^dity days, or forty weeks, or ten lunar months
must at once direct attention to the fact that labor comes on
at the tenth menstrual period since pregnancy began. At the
menstrual period in the non-pregnant uterus there is always dis-
tinct muscular action, induced probably by the presence of a
foreign body — blood — in the uterine cavity. During pregnancy it
has long been known that by the unconscious memory of living
tissue there recurs, at regular internals corresponding to the
menstrual period, a disposition to muscular action, which is
sometimes so exaggerated as to bring about an expulsion of the

LABOR. 287

ovum, — an accident especially to be feared at such times in women
prone to abort. Here, then, is a cause predisposing to uterine
muscular effort at each recurrence of the time for the absent
menstrual flow, especially the tenth, and this, therefore, must be
accepted as one at least of the causes of labor. It is described
conveniently as periodicity,

A study of all the hollow muscles in the body shows
that they admit of distention up to a certain point, but, that
point being reached, they are immediately stimulated to con-
traction. This is well illustrated in the stomach of the young
infant, which nurses until the organ, overfilled, contracts and
expels the excess of food which its cavity can not contain. So,
too, in the ventricles of the heart, distention with blood goes on
to a certain extent, when contraction occurs and the blood is
driven into the great arterial trunks. Precisely the same action
may be seen in the pregnant uterus. It admits of distention up
to a certain point, until it is well filled by the mature fetus, when
the great tension of its walls, no longer endurable, stimulates
them to muscular action which terminates in the expulsion of
the ovum. This cause of labor is defined as cnu^rdistcntion of the
uterus.

Just as in plant life certain degenerative changes occur in the
supporting stem of fully ripe fruit which makes its connection
with the parent branch so frail that a slight breath of wind
causes it to fall to the earth, so in the human ovum that has
reached full maturity there occurs a degenerative process, a fatty
change, in the connections which bind the ovum to the uterus,
which brings about a separation more or less extensive between
the uterine wall and the ovum, and the latter, becoming a foreign
body in the uterine cavity, is cast off.

This cause of labor is called the maturity of the 07.nnn,

Finally, heredity, the unconscious memor>' of tissue trans-
mitted from generation to generation, plays a most important
role in the causation of labor. Thus, at the end of two hundred
and eighty days the fetus has reached such a size that it is just
fMDSsible for the woman, at the expense of much effort, to expel it
through the birth-canal. Had it grown much larger, its expul-
sion would be diflficult or impossible. On the other hand, an
infant bom much before two hundred and eighty days is not
sufficiently well developed to endure the lower temperature that
it encounters, and the necessity for obtaining its own nourish-
ment and oxygen, and consequently it will not surx^ive. There-
fore, it is plain that only those women who gave birth to their
oflfspring about the two hundred and eightieth day of pregnancy
could successfully perpetuate the human species. Those that

288 LABOR AND THE PUERPERIUM,

fell in labor later probably died ; those whose young were bom
earlier were not able to rear them ; and so the habit of bear-
ing children at the end of forty weeks from conception, trans-
mitted from generation to generation through many ages, became,
perhaps, the most powerful influence in determining the duration
of pregnancy.

To recapitulate, then, labor comes on at about the two hundred
and eightieth day from the beginning of the last menstrual period,
because of the influence of periodicity ; as a result of the over-
distention of the uterine cavity ; in consequence of the maturity
of the ovum, and by reason of heredity. All these causes being
operative together, it requires only some very slight stimulus or
none at all to inaugurate effective uterine contractions. Just as
a single blow of a workman's hammer will start the launch of a
ship when everything is prepared for it, so here a little exercise,
a dose of purgative medicine, a jolt or a jar may provoke mus-
cular action on the part of the uterus that ends in the expulsion
of the child. This knowledge is often put to good practical
use. If one fears that labor might be delayed in a given case,
and there were factors in that case which made such delay
undesirable, by resorting to some stimulus a little more effective
than the ordinary occurrences of ever^^-day life, one secures the
onset of labor at its proper time. Thus, if the two hundred and
eightieth day from the beginning of the last menstrual flow is
accurately determined, one might, the night before this last day,
give a dose of some purgative medicine — castor oil — and follow
this the next morning by a good dose of quinin — say, ten grains
— to insure the beginning of labor at its normal date.

Before entering upon a study of labor the student should be
sure that he is able to recognize its occurrence.

The diagnosis of labor, therefore, is a necessary preface to
the study of its physiology and management. First and fore-
most, in the woman supposed to be in labor, the existence of
pregnancy should be determined. Many ludicrous and some
tragic errors have been committed by a disregard of this rule. ^
There is a valuable premonitory sign of labor which should
always be inquired for : the subsidence of the uterine tumor at
periods varying from four weeks in the primigravida to two weeks
ftr less in the multigravida before the actual advent of labor.

V on duty in the out- patient obstetric de|>artment, receiving

^miian^s house, spent some fifteen minutes sterilizing his

vaginal examination, much to the patient's surprise, as

ccxmnt of rheumatism. She was not pregnant.

n expert witness in a trial for damages on account

The patient, a rachitic dwarf, was not even preg-

ned.

LABOR. 289

This sinking of the uterine tumor is the result of the engage-
ment of the lower uterine segment with the presenting part of
fetus in the superior strait and in the cavity of the pelvis. It has
its cause, probably, in the action of the muscles inclosing the
abdominal cavity. Just as the stomach, the heart, and the uterus
bear distention up to a certain point, so the abdominal mus-
cles allow a certain distention of the abdomen to occur, but
resent anything beyond it. This point is reached in primi-
gravidai at about the thirty-sixth week of pregnancy, but later
in multigravida^ owing to a greater laxity of their muscles.
The abdomen being distended to its utmost, the abdominal mus-
cles contract vigorously and drive the lower part of the uterus
down through the superior strait into the cavity of the pelvis by
diminishing the area of intra-abdominal space, thus accomplish-
ing the first step in the expulsion of the child, the passage of
the head, presuming it to be a cephalic presentation, through
the superior strait, long before the labor itself begins. This
sinking of the fetus and uterus occurs often suddenly, so that
the pregnant woman may rise one morning entirely relieved of
the distressing abdominal pressure symptoms that had previously,
perhaps, tormented her. But the relief in one direction is fol-
lowed by an aggravation of the varices about the vulva, anus,
or lower limbs, by neuralgic pains extending down the thighs,
by increased vaginal secretion, — all due to the greater pressure
within the pelvic cavit}\ So constant is this phenomenon, the
descent of the pregnant uterus near term, that, should it fail to
occur, some cause for the failure should be looked for. It will
usually be found to be a malposition of the fetus or a deformity
of the pelvis.

There are three signs indicating that labor has actually
begun : (i) Recurrent pains of characteristic duration, situation,
and nature ; (2) the escape of a small quantity of blood-tinged
mucus from the vagina, and (3) the dilatation of the os. The
characteristic pains of commencing labor recur at intervals of
from five minutes to half an hour, usually being about fifteen
minutes apart. The pain is located in the abdomen, or is de-
scribed as passing from the umbilicus in front to the sacrum
behind, or in some cases is confined altogether to the back.
It comes on suddenly. The woman is walking about the
room, or perhaps conversing, when suddenly she pauses,
bends over, contorts the facial muscles a little, sets her lips,
and clinches her teeth. The pain rarely lasts more than a
minute ; when it passes off the woman resumes her inter-
rupted occupation. If the hand were laid over the abdo-
men when the pain came on, the uterus would be felt as a
19

290 LABOR AND THE PUERPERIUM,

firm, hard, well-defined body, more globular than in its relaxed
condition.

As a consequence of the beginning dilatation of the internal
OS, the lower portion of the ovum begins to sever its connection
with the uterine wall, and in doing so the delicate blood-vessels
that may yet run in isolated places into the decidua are torn, and
there is a slight oozing of blood, which stains the large plug of
tenacious mucus that has filled the cervical canal during preg-
nancy. The cervax being gradually obliterated from above
downward by the descending ovum, the blood-stained plug of
mucus is expelled from the cervix into the vagina, whence it
escapes externally and becomes what is popularly called the
shou\ which is regarded, and rightly, too, as a valuable sign of
beginning labor. But the uterus may contract quite vigorously
and bloody mucus may escape externally in many a case when
labor has not really begun. The most reliable sign, after all, is
the obliteration of the cervical canal and the dilatation of the
OS. If these conditions become plainly appreciable, one may
safely diagnosticate a beginning labor, although it would be
well to bear in mind exceptional cases in which the os has
actually dilated up to an inch or more, but has afterward re-
tracted and remained undilated until true labor finally appeared. ^

Having made a diagnosis of beginning labor, the physician
is immediately plied with questions by the patient or her
family as to its probable duration. This is a question that is
put to every practitioner of obstetrics in almost every case, but,
unfortunately, it can not be given a definite answer. It is a
common experience to see a variation in the length of labor from'
one hour or less to many hours ; indeed, in rare cases to a week
or more. So that it is impossible to predict with any degree of
accuracy how long a given labor might last. One can usually
obtain an approximate idea, however, by bearing in mind the
average duration of labor in multiparas, eight hours, while in
primiparas the time is usually double that or longer. One
should recollect that a large parturient canal with a normal fetus,
or one undersized, along with vigorous muscular action, means
a quick labor ; that the opposite conditions mean delay. In the
case of multiparas one should always inquire into the history of
past labors, for many women have marked individual peculiari-
ties in regard to the duration of parturition, in some the process
being usually rapid and easy, in others the reverse. A consid-

a young primipara with the os dilated so that I could put foui
Uito it, and with the nienil)ranes bulging into the vagina, who
» for a week in this condition before lalx^r-pains appeared. In
however, the cervical canal was not effaced.

LABOR, 291

eration of all these factors will enable one to form some definite
idea in his own mind of the probable duration of labor, but he
would do wisely to keep his opinion to himself. To the inquiring
family a non-committal statement should be made, such as ** the
length of the labor will depend on the strength of the pains." ^

Before proceeding to a consideration of the management of
labor, the student will find it of service to observe the process
as a passive spectator. Nothing is so conspicuous in the first
stage of labor as the contractions of the uterine muscle. It has
been asserted that the uterine walls contract in a sort of peris-
taltic wave, beginning at the cervix, running up over the fundus,
and returning again to the cervix ; but this action has never been
actually demonstrated, and it is more convenient, if, indeed, it is
not strictly correct, to regard the uterus as a hollow muscle
which contracts at once and equally in all its parts. The eflfects
of these contractions are : (i) To drive the liquor amnii in the
direction of least resistance, which is through the internal os
into the cervical canal, where, contained in the membranes, it
dilates the cervical canal in the very best manner for the mater-
nal tissues, as a hydrostatic dilator. (2) To drive down the
fetal mass in the same direction by diminishing the area of the
intra-uterine space. (3) To distend the lower uterine segment
and upper cervical canal by mechanical pressure, and, finally, to
dilate the os in the same manner after the circular, sphincter-like
muscle of the cervix has been paralyzed by stretching and pro-
longed pressure. The average duration of these uterine con-
tractions during labor is one minute. The intervals between
them decrease as labor goes on, and the pains become more
powerful until, finally, there should intervene between them but
two or three minutes. No one could observ^e the process of
parturition in the capacity of a scientific observer without re-
garding the action, appearance, and condition of the woman. It
will be found that her whole bearing and manner present two
distinct types in the course of the process. At first the advent
of each pain is announced by a sudden setting of the teeth,
a distortion of the facial muscles, suffused eyes, and a flushed
face, and, the pain increasing in intensity, she suddenly emits
a sharp cry of pain. The woman, if in bed, assumes almost
any attitude that is most comfortable to her. In a normal
first labor of some seventeen hours' duration, this condition

* As those labors which end in the day-time often begin at night, and vice versft,
an obstetrician's rest is disturbed in a very large pro|x)rtion of his cases. There is,
consequently, a prevalent idea that almost all confinement cases occur at night. As
a matter of fact, forty per cent, only are delivered between the hours of 1 1 p. m. and 7
A. M., according to the statistics of West, based on 2019 cases (" Amer. Med.
Jour.," 1854).

293

LABOR A,\-D TUB PUERPERIUM.

of affairs lasts about fifteen hours, when a marked change
may Idc observed in the woman's action. If she were left
entirely to herself she would be very likely to assume a
squatting posture in bed or upon the floor, — a position assumed
by the women of many savage tribes during the latter stage of
labor. Now, as a pain comes on the woman draws a deep
breath, clinches her tectlj. fixes her diaphragm, and evidently,
from her behavior, calls into play the action of the abdominal
muscles with all her might. Her face is suffused, the eyebrows
knit, and beads of perspiration stand out upon her brow. As
long as the breath can be held this straining action is continued.

l-'ig. 18a.— The b*e of waters

until the air is suddenly expelled from the lungs with a charac-
teristic grunting sound, the diaphragm is again relaxed, and the
abdominal muscles cease for a moment to act until a full in-
spiration is taken, when the straining again begins, and continues
until the uterine contraction passes off. If one made a vag-
inal examination at this time, he would find a good reason for the
change in the clinical aspect of the case. It would be found
that the os is fully dilated and that the presenting part is begin-
ning to descend, either carrying the membranes before it or else,
as is more common, the membranes rupture just as the os is
fully dilated and the child's presenting part is driven through
the rent in the amnion and chorion. In this condition of aRairs

LABOR. 293

is found a good explanation for the action of the abdominal
muscles ; so long as the presenting part acts simply as a wedge,
dilating the os, but not descending to any appreciable degree, the
muscles of the abdomen are useless, and are. in fact, inhibited,
for their action would drive the presenting part against the undi-
lated cervix with such force as to gi\'e great pain, if not to do
great damage. The main obstruction to the descent of the
child, the cervix, being removed, the abdominal muscles are
called into play, and act cffeclivdy in the displacement of the
fetal body downward along the birth-canal. For convenience
definite names are given to these stages of labor, presenting
each such distinctive features. The period of dilatation is called

jf ihc: chilli's scalp.

the first stage ; the period of descent or expulsion is called the
second stage. The first stage begins with the onset of labor
and ends with the complete dilatation of the os. The second
stage begins with the dilatation of the os and ends with the
complete expulsion of the child. As labor is not complete until
the whole ovum is expelled, there is a third stage of labor, that
period of time from the extrusion of tlie fetus until the pla-
centa and membranes are expelled.

To return, however, lo the clinical phenomena of labor. The
woman has passed from the first to the second stage. As
the latter progresses the pain becomes more frequent and violent,
the woman's suffering is increased, and her complaints grow

294

LABOR AND THE PUERPERIUM.

louder. Finally she declares, perhaps, that she must rise to
evacuate her rectum and bladder, and the reason for this feel*
ing is clear when one sees the perineum bulging far outward, the
anus widely dilating, the rectum becoming slightly everted, and
the presenting part, the head, filling up the whole lower part of
the pelvis and pressing as firmly on the bladder in front as it
does on the rectum behind. And now. with his eye upon the
vulva, — for this part of the labor, in the best interests of the

patient, ought always actually to be observed, both in a scientific
study of the process and in its management, — the physician sees
the labia separate during a pain and the child's scalp come into
view, but. with the subsidence of the pain, disappear. With the
next uterine contraction a little more of the head appears, again,
however, to disappear as the pain passes off", and so on with
every pain for perhaps twenty minutes or an hour, although
every time, as more and more of the head appeiirs, it looks to
the inexperienced observer as if that pain must be the last, until

LABOR, 2g5

finally the vulva is stretched to its utmost limit and the largest
dianieters of the head are engaged, when, with a sudden shriek
of pain from the woman, the child's head is bom. There comes
then a pause in the uterine action ; the head may protrude from
the vagina for a minute or much longer, while the woman's
natural powers are being recuperated, after their tremendous ex-
ertion, for a fresh effort. Meanwhile, the child's face turns im-
mediately after birth toward one or the other tuber ischii, and

Fig. i8j.

from the constriction about the neck becomes livid, and it seems
tiiat the child's life is threatened by strangulation. The medi-
cal attendant feels at first an almost irresistible impulse to pull
on the head and terminate labor. But this is a useless, indeed,
a reprehensible procedure, for the child is perfectly safe, its
respiration still going on normally in the placenta, and to ex-
tract the shoulders rapidly through the overstretched and
bruised maternal dssucs is almost certain to lacerate the peri-

296 LAftOK AND THE PL'ERPEKtUM,

neum. Moreover, the child is insensible at this time ; it lias
been almost comatose during its passage through the pelvic canal,
and is now recovering, its brain -centers, especially that of respi-
ration, becoming ready to respond to the stimulus to act when
the child is born. Any unnecessar)' interference, therefore, at
this stage of labor may harm botli mother and child. The
woman's uterus having regained power, in a few minutes begins
to contract. The abdominal muscles aid it. The child's face
turns still more to one side or the other until it looks quite
transverse. The expulsive force still acting, the anterior shoulder
appears under the symphysis pubis, the posterior shoulder
shortly afterward sweeps over the [>erineum and escapes ; the

Ffg. 184. — Tbe support of the head and the escape of the Bnlerior shoulder

anterior shoulder follows it, and the rest of the body, too small
to present any longer an effective resistance, is expelled im-
mediately and the child is born. Its birth is announced, as
a rule, at once by a lusty cry, which expands its lungs and
initiates the pulmonary respiration. Immediately after the ex-
pulsion of the child the woman becomes perfccth' quiet and
composed, no matter how noisy she may have been before.
The pa.ssive pleasure of being free from suffering is so great that
it becomes a positive enjoyment simply to be quiet, and the
woman does not wish to be disturbed. In the course, however,
of some fifteen or twenty minutes, in a perfectly natural and

LABOR, 297

normal case, such as is now under description, the patient again
experiences pain ; the uterus is again contracting, and the woman
is again instinctively aiding it with her abdominal muscles, until
after one or two such pains the placenta with the membranes is
expelled.

The manner in which the placenta is separated from the
uterine wall and is expelled from the uterine cavit>' is a matter
still under dispute, and there is the greatest difference of opinion
in regard to it. ** If,'* says Dr. Berry Hart, the distinguished
obstetrician of Edinburgh, ** the delivery of the placenta de-
pended upon obstetricians knowing how it separated, no woman
in labor would complete her third stage." This lack of definite
information is unfortunate, for an accurate idea of the mechanism
of labor in the third stage is most desirable if one would treat
this period of labor intelligently. To explain the first phenom-
enon, the separation of the placenta, many theories have been ad-
vanced, of which I shall give only the three most reasonable, each
of which has its prominent adherents. These three theories are :
(i) The diminution in the area of the placental site ; (2) the de-
trusion theory, which is founded on the belief that the uterus
seizes the placenta and pushes it off from the uterine wall ;
and (3) the theory that an effusion of blood occurs behind the
placenta, and that this " retroplacental effusion," as it is called,
pushes off the placenta from the uterine wall. Of these three
theories, I am an adherent of the first. In a strictly normal case
the retraction of the placental site is alone sufficient to account
for the separation of the placenta. It has been demonstrated
that, as the uterus contracts, the placenta follows the retrac-
tion of the uterine walls up to a certain point without becom-
ing detached, until the placenta is reduced to about one-half
its natural size. Now, this is easily explained if one recol-
lects the structure of the placenta, like nothing so much as
a sponge, with its branching villi and intervening natural blood-
spaces. But as soon as these villi are squeezed together
so that the placenta forms one solid mass, it can no longer
follow the retraction of the uterine wall, but is that moment,
in a typically normal case, sprung off from its attachment
to the uterus, and is for a var>ang period of time loose within
the uterine cavity, until, acting as an irritating foreign body
upon the uterus, it is finally driven out into the cervical
canal and upper part of the vagina by the uterine contractions
that its presence within the uterus excites. In the cervix and
vagina, however, the placenta may remain a long time without
exciting the benumbed and almost paralyzed muscles of these
regions to action. And thus it is that, in civilized women, at

298 LABOR AND THE PUERPERIUM.

least, it is often impossible to leave the third stage of labor
entirely to nature, for the placenta may remain so long undeliv-
ered that its succulent mass may putrefy and so become a
source of septic infection. In describing a perfectly normal case
of labor, I must presume that the placenta is expelled by the
natural forces, and must describe the manner of its expulsion.
But here, again, one encounters the greatest difference of opinion,
even about so apparently simple and trivial a matter. One
set of observers, led by the English obstetrician, Matthews
Duncan, declares that in natural labor the placenta comes out
edgewise, and that any other mode of exit indicates something
abnormal ; while Schultzc, of Germany, and his followers de-
clare that the placenta always escapes like an inverted umbrella.
My observation compels me to adopt the latter view.

In consequence of the enormous effort put forth, the nervous
excitation, the acute suffering, and the injury inflicted upon the
soft structures of the birth-canal, it is not surprising that sys-
tematic thermometry of the recently delivered woman shows
almost always some elevation of temperature in the first twelve
or twenty-four hours after child-birth.

After a brief observation of the main clinical phenomena of
labor, the student is better prepared to take up a consideration of
its management. The advice offered applies to private and not
to hospital practice, and to the beginning of the process. In
the vast majority of cases a physician is engaged to attend a
woman in confinement a considerable length of time before labor
is expected, and there are certain important points in the pre-
liminary management of the patient which it is important to
appreciate, but they have been considered in the section upon
the management of pregnancy. The present section begins with
the first intimation that the doctor receives of beginning labor,
the summons to attend his patient in confinement. The call
may come at the most inconvenient time, — late at night ; in the
early hours of the morning ; at the beginning of a meal ; in the
midst of a press of other work, — but no one should practise ob-
stetrics who docs not make it an inflexible rule to give such
a summons precedence over everything, over personal con-
venience and all other enLraijenicnts.

It is customary, in this connection, to offer advice to young
practitioners in re<j^ard to their personal demeanor and appear-
ance when about to attend a woman in labor. While such ad-
vise is usually suiK^rduous. it docs no harm to remind the phy-
sician of the especial rccjuircniciits in this particular kind of medi-
cal work. He should remember that the irritability and in-
creased sensibility characteristic of pregnancy are even more

LABOR, 299

exaggerated during labor. Any unusual appearance in the
medical man — slovenliness of dress, abruptness of speech and
manner, harshness of voice, the odor of liquor on his breath or
that of tobacco in his clothing — may have the most unfortunate
effect upon his patient. Bearing in mind the increased sensitive-
ness of women in labor, recollecting that the agony which
they are about to endure, and that the despondency which comes
of the dread of impending suffering, if not of death, demand espe-
cial sympathy and consideration, no one fitted by nature for the
practice of medicine will go far astray in his conduct toward his
parturient patients.

A more important question arises as soon as a physician
is summoned to a case of labor. What shall he take with
him ? As a part of his management of the pregnant woman he
has directed the patient or her friends to have at hand the
articles enumerated in the list of directions to mother and nurse
on pages 347-349. A fairly well-equipped obstetrician should
take with him in his obstetric bag, to an ordinary case of con-
finement, the following articles :

A metal box containing scissors, needles, suture material,
perforated shot, at least two hemostats, needle holder, and a
small alcohol lamp to boil the above.

Two boxes or bottles of iodoform gauze ( i yd. in each) ; a
package of sterile gauze (i yd.).

A box of five per cent, carbolated vaselin.

A bottle of aseptic silk ligatures for the cord.

A small package of absorbent cotton.

A hypodermatic needle, with the customary pellets.

A bottle of the fluid extract of ergot.

An obstetric forceps.

A bottle of bichlorid of mercury tablets.

A small Gaiffe battery, or other electric battery, and a soap-
box and nail-brush.

A metal box, a stand, and a lamp should fit in the bag, for
boiling the forceps.

^Arrived at the dwelling to which he has been summoned,
the physician finds the woman in the room selected for her con-
finement, which should be, if possible, the sunniest and best
ventilated in the house, and in care of a nurse in whom he has
confidence from past acquaintance or from good recommenda-
tion. He has been summoned because the woman believes her-
self to be in labor, but she may be mistaken, or, on the other
hand, may be much farther advanced than she imagines. It is
the physician's first care to determine this point, and to do it he
must make an examination. This the patient fully expects and
will in no way object to, but it must be done in a manner as

300 LABOR AND THE PUERPERIUM.

little revolting to her feelings as possible. After a few indifferent
remarks in a quiet tone to the patient ; a few questions in regard
to the time the pains first came on, their duration, character, and
situation, and the intervals of time between them ; after feeling
the pulse, perhaps, and looking at the tongue, and assuring her
that her general condition is very good indeed, the nurse is
informed that she is to be prepared for abdominal palpation.
While the nurse is arranging the patient on her back with a
single layer of some thin material, as a bed-sheet, spread smoothly
over the abdomen, the physician himself either leaves the room
or turns his back upon the bed while he dons a surgical gown
and gives his hands a preliminary washing.

This whole subject of the obstetric examination is so im-
portant that space may well be devoted to its consideration.

Abdominal palpation is described fully in the chapter upon
The Mechanism of Labor. It is, therefore, only necessary to
state here that, after determining the position of the fetus
in utero, and investigating the condition of the fetus by listening
to its heart-sounds, the nurse is directed to place the patient
upon that side toward which the fetal back looks and to pre-
pare her for a vaginal examination. For this purpose the
parturient woman is placed upon her side, with the hips brought
well to the edge of the bed, the thighs flexed upon the abdomen,
the legs upon the thighs. The clothing is rolled up above the
waist, or so arranged that it shall not interfere with the access of
the examining hand, and the bed -sheet is draped over the patient
so that a wide margin of it falls over the side of the bed. While
this is attended to the physician is cleansing his hands by a
method described in the chapter on the preventive treatment of
puerperal sepsis. He uses that hand for the internal examination
which is next the patient, as he takes his seat alongside of the
bed, facing the patient's genitalia. Everything being in readi-
ness for the vaginal examination, the examining fingers are
anointed with carbolatcd vaselin, the nurse lifts up the sheet
covering the buttocks, the obstetrician raises the upper buttock
with his free hand, and by the sense of sight inserts the forefinger
of the examining hand directly into the vaginal orifice. Nothing
is more foolish than the common practice of groping about under
a sheet for the woman's genitalia, thus dangerously soiling the
examining hand which had been made sterile by a painstaking
disinfection, only to be infected again before its insertion into the
vagina. The ability to derive easily all the desired information
from a vaginal examination only comes from practice and an
^^Hon of the tactile sense. It would be well, therefore, for
ler, in the beginning of his obstetric experience, to

LABOR. 301

bear in mind a series of questions in their natural sequence,
which he desires to have answered, and to persist in his eariier
cases until repeated and long-continued examinations have satis-
fied his mind. Thus : the character of the vaginal discharge ; the
state of the perineum, whether relaxed, rigid, or torn perhaps
from a previous labor ; the rigidity and distensibility of the
vaginal walls and the quantity of secretion upon them, — nature^s
lubricant ; the capacity of the pelvis ; the condition of the cervix,
whether it is rigid or yielding, thickened, edematous, or thinned
out ; the degree of dilatation of the os ; the portion of the fetal
ellipse which is presenting itself at the os ; the engagement of
the presenting part in the pelvis ; the position that the present-
ing part may have assumed ; the rupture or the integrity of the
membranes ; and, if the examination continues during a pain,
the effect of the expulsive forces upon the fetal mass. All these
are questions of great importance in their bearing upon the diag-
nosis of the woman's present condition and upon the prognosis
as to the character, duration, and termination of the labor.

Having satisfied his mind upon all these points, the obstetri-
cian enters upon the management of labor.

The very first step in the treatment of the first stage of labor
should be the evacuation of the rectum. The capacity of a nor-
mal pelvis is none too great to permit the passage of the fetal
body ; but if the pelvic canal is occupied by a distended rectum
full of feces, labor may be delayed, the woman's suffering is
materially increased, and the danger of a tear in the greatly dis-
tended vagina is considerably augmented. It is only the rectum
and sigmoid flexure that need be emptied, and this result is best
secured by an enema of a pint of soapsuds with a teaspoonful
of turp)entine in it. A well -trained nurse will already have
done this, perhaps before the doctor's arrival, if she thinks that
labor has really begun. The enema acts quickly and effectually,
whereas a purgative administered at the beginning of labor, as
has been recommended by some obstetricians, begins its action
possibly when the os is too much dilated to allow the woman to
use a commode. The lower bowel being emptied, the woman, with
advantage and comfort to herself, may be allowed to walk about
the room or to sit up in a chair, the physician making an ex-
amination from time to time to determine the progress of labor
and to avoid the serious accident of a precipitate deliver}' in
the erect posture, an accident dangerous to the mother and
usually fatal to the child. This statement leads to the inquir\''
how often and how long to examine a parturient woman in the
first stage of labor, and how long she should be allowed to re-
main out of bed in a standing or a sitting posture. In a normal

302 LABOR AND THE PUERPERIUM,

case during the first stage of labor, the intervals between the
examinations are from two to four hours, or even longer. But
two or three examinations need be made during the whole labor.
As to the time for putting a woman in labor to bed and keep-
ing her there, it is usual to lay down the rule that as soon as
the OS has reached the size of a silver dollar the woman should
be confined to bed. Many patients might be allowed to be up
longer than this, while others with a history of, or conditions
predisposing to, quick labors must be put to bed earlier.

Many patients express a desire to go to the water-closet at
about this time, but their request can on no account be allowed.
Many a woman has discharged her infant into the seat of a
water-closet or into the well of a privy, either by design or
under the impression that she was having an evacuation of the
bowels. 1

Before the woman is put to bed it should be arranged for
the labor in the manner illustrated in figure 185. The mattress
is protected by a mackintosh and the bed-sheet is, guarded by a
pad of nursery cloth.

As the first stage of labor advances, the suffering of the
woman increases with each succeeding pain. She complains,
perhaps, bitterly, and the suffering becomes so great, in occa-
sional instances, that the patient seems to be maniacal or to
become completely exhausted, not so much from muscular effort
as from an agony that is beyond endurance. She appeals to
her medical attendant to do something to relieve her suffering,
and her appeal is enforced by all the appearances of the greatest
anguish, perhaps, that a human being is called upon to endure.
Any sympathetic person must feci impelled to grant this
request, to resort to some of the well-known agents for lessen-
ing pain that medical science is now possessed of The only
consideration that could deter him would be the fear that these
remedies entailed dangers upon the woman that he dare not
risk even to secure the immense relief of pain that they would

^ The resident physician on my service at the Howard Hospital was called to a
house in the neighborhood, and fished out of the privy- well, twelve feet deep, an infant
which had been immersed in the contents of the well up to its neck for eight hours.
The mother had deliberately sat upon the seat until her baby dropped from her. She
had then thrown three bricks down upon it. In sjiite of these disadvantages the child
was extracted alive, by means of a pole and some twine. It was received into my
wards at the Philavlclphia Ilosjiital, where it thrived. On another occa.sion one of
the j^atients in the rniver>ity Maternity locked herself in the water-closet, dropped
her baby down the bowl, and turned on the watrr. A nurse's attention was at
length attracted to a stream of water running acr<)>-< the floor of the corridor. The
water-closet door wa> i>roken open, the woman pulled otV the seat, and the child,
whose head accurately stopped up the exit-pipe «>f the bowl, was extracted alive,
though it had been under water probably live minutes. All cases of this kind do not
end so fortunately.

L/4B0X. 303

aflbrd. It has been demonstrated that such a Tear is not justified
by facts. The dangers and disadvantages that, it is claimed, result
from the use of anesthetics in labor are : a prolongation of the
process by weakening the uterine contractions and increasing the
intervals between them ; a disposition to postpartum hemor-
rhage ; an increased liability to sepsis after labor by a relaxation
of the uterine muscle, and a subinvolution of the uterus.
These objections are ill-founded if the anesthetic is administered

Fig. 185, — Bed imaged for child biilh. The mattress is protecled by n miickin-
losh, over which ■ clean sheet is sprcdd. The upper bed-clothes are rolled up at the
loot of the bed. The womaa's bullocks rest u^un a square yard of nursery cloth.
The chMr is for the obstetrician ; at hi* feet is a wasle-buckel. inio which the pledgeU
of cotloD used 10 clean the anus are thrown. The tabic, in easy reach, has upon it
a large hafin of sublimate J^o1u1i□^, 1 1 3000, in which are manv lai^ pledgets of cot-
ton ; a small tin cup on an alcohol lamp to boil the scissors for the cord ; a half doien
clean towels ; a pot of catbolnlcd vaselin ; a lumbler of horic-acid soluliim with
squares of clean sofl linen in il for the child's eyes and mouth ; a tube of sterile silk

lot ihc cord.

in a proper manner. Accurate observation in some of the large
German lying-in hospitals has demonstrated that an anesthetic,
if not pushed too far, has no influence on the power, duration,
or frequency of the pains. By relieving the dreadful suffering
in some cases that causes an exhaustion as profound as would
follow tremendous physical eRort, the danger of postpartum
hemorrhage is actually avoided. Subinvolution is never seen
as A result of anesthesia, unless it is pushed too far. Upon these

304 LABOR AND THE PUERPERIUM.

negative facts ; upon the gratification that it gives every medi-
cal man to reUeve intense suffering ; upon the enormous relief
experienced by the patient and her gratitude for the aid afforded
her is based the practice of giving an anesthetic in ever\' labor
in which its use is required. There are many women — and they
will form the majority of a physician's patients in the countr\',
I think — to whom labor is not so trying an ordeal ; is, in fact,
little more than an inconvenience or a discomfort, and by no
means an agony. Women have been known to expel a full-term
child when they were hardly conscious that labor had begun.
To resort, therefore, to an agent to abolish suffering when it
does not exist or can be easily endured is obviously absurd.
Granting that in many cases anesthesia in labor is an advan-
tage, if not a necessity, the physician must select the anesthetic
agent he shall employ, and must determine when and how he
shall use it. The choice lies between ether and chloroform.
Cocain, it was thought at one time, would be an efficient local
anesthetic, but it proved a failure. Belladonna, applied locally
to the ccr\ix, is also of no service to relieve pain, although it
diminishes rigidity ; the same may be said of chloral, taken
internally. I take it that the choice in the eastern seaboard
of the United States will usually be for ether. Chloroform
is in disfavor in this part of the world, although, perhaps, un-
justly. Kther is an efficient, convenient, and satisfactory agent
as an anesthetic in obstetrical practice, except, of course, in the
treatniLMit of eclampsia. There are, however, two precautions
to be observed in its administration, — not to giv^e it too long,
and not to <;i\o too much of it. The first error is avoided by
beginnini; its adniinistration as late in labor as possible ; 'it is
better to put off the resort to an anesthetic until the second stage
of hibiM*. when the suffering in the first stage is not too great.
One avoids L^ivini; too much : ( i) By using a light towel throuTi
over the lace and dropping only a few drops at a time, just
below tiic tip of the nose, at the end of an expiration, so that
the whole \ a})or is sucked into the lungs with the succeeding
inspiration; (j) by only beginning the administration of ether
as the pain conios on. and discontinuing it in the interx'-als ; and
(3) h\' endeavoring; to produce not complete anesthesia, but
onl\' anali^esia. It is astonisjiing how little ether it takes to do
this. An\' <Mic can demonstrate in his own person that a few
decj) inspirations make the skin insensible to a sharp pinch or to
the |)rick of a knife. A succession of these inspirations from
pain ti> pain soon dulls tiie edge of the woman's suffering, and
makes it tjuite ciulurable.

As labor acKances and the first stage is about to pass into

LABOR, 305

the second, one should expect the rupture of the membranes and
the escape of liquor amnii ; so he will wisely make some prepara-
tion for the occurrence. Provision must be made for the sudden
escape, often rather startling to the patient or to an inexperi-
enced practitioner, of a pint or more of liquor amnii, which must be
caught in some clean towels or on a large, new sponge, one which
has never been used before and should never be used again
about the patient.

If the membranes fail to rupture at the end of the first or at
the beginning of the second stage of labor, the physician must
consider whether he shall artificially break the bag of waters. In
the case of a primipara such interference is not justifiable. The
bag of waters is a perfect hydrostatic dilator, acting without
great force, and in primiparae a slow, gradual, and conservative
dilatation of the maternal soft parts is most desirable, to avoid
lacerations of the cervix, vagina, or perineum. In multiparae
the artificial rupture of the membranes is admissible after the
completion of the first stage of labor ; the interference certainly
hastens the expulsion of the child, and as the soft parts of a
woman who has already borne children are distensible there is
not the same necessity for care to preserve nature's conservative
dilator. Under no circumstances, in any ordinary uncomplicated
labor, should the membranes be ruptured before the full dilata-
tion of the OS. Any one who has observed what in the nurse's
parlance is called a dry labor — that is, one in which the mem-
branes rupture early — ►will not dispute this assertion. Occasion-
ally, even in primiparae, the first intimation that a woman receives
of the beginning labor is the escape of the liquor amnii, the mem-
branes having ruptured before the os is at all dilated. In these
cases the labor is longer, the woman's suffering is much greater,
and the likelihood of damage to the maternal tissues is very con-
siderably increased, as can readily be imagined when one considers
that the dilatation of the birth-canal is effected not by the yielding,
elastic bag of w^aters, but by the hard, unyielding mass of the
fetal head. Occasionally, however, in the case of a multipara in
the second stage of labor with unruptured membranes, the phy-
sician must be prepared to perform the rather trivial manceuver
of artificial rupture of the membranes with skill and without
injury to the fetal or maternal structures. This sounds simple
enough, and yet experience has shown that certain precautions
are necessary. In the first place, the membranes are not to be
ruptured during a pain, for the sudden gush of liquor amnii might
carry with it a loop of the cord. It must be clearly established
that the tissues to be punctured are the membranes, and not
the child's scalp or the distended lower uterine segment. It
20

3o6 LABOR AND THE PUERPERIUM.

is often possible to hook the finger-tip into a fold of the mem-
branes and to tear them by pulling outward. They may also be
pinched through between the forefinger and the thumb or middle
finger. If these manual methods do not succeed, an ordinary
match with the phosphorus cut off, sharpened at one end and
then well soaked in a sublimate solution, may be introduced
held between two fingers, and the membranes perforated with this
simple instrument ; or an ordinary hairpin, straightened out,
after being flamed, proves an efficient implement.

During the second stage of labor a new and a very important
element enters into its mechanism, — the powerful action of the
abdominal walls. Indeed, it has been claimed that the con-
traction of the abdominal muscles is the principal, the uterine
force the secondary, expulsive power in this stage of labor. By
the employment of a "puller" which fixes the chest above and
the pelvis below, the power of the abdominal muscles may be
utilized to its utmost extent. This is done by fixing the feet
against the foot-board of the bed, and attaching to one comer
of it a rope or a twisted sheet on which the woman can pull with
her hands.

The straining accompanying the uterine action, denoting
that the second stage of labor has begun and that the presenting
part is descending into the birth-canal, lasts in the typically
normal case about an hour and a half or two hours, when, if the
physician observes the genitalia, — and the period of labor has
arrived when it is desirable actually to observe the process, — he
notices that the anus is opened and the rectal mucous membrane
is exposed to view ; with every pain small masses of feces are
extruded from the anus which must be wiped away always
toward the coccyx with large pledgets of cotton soaked in sub-
limate solution : the perineum bulges outward, and the vulvar
orifice opens a little, disclosing a small portion of the child's
scalp. With every pain the perineum become.s more distended,
the vulva gapes more widely, until, finally, the perineum, by the
tremendous tension to which it is subjected, becomes almost
as thin as paper, and it seems a physical impossibility for the
head to escape through the vulva without tearing liie over-
stretched ti.ssucs that form the pelvic floor. In fact, frequently I
the fetai head does make a way for itself through the perineum, jj
instead of over and in front of it as nature intended, a ' "
labor there is found a more or less extensive laceration <
pelvic floor. Schrncder'.s .stnti.stics show that in |
fourchet. the little fold of skin at the posterior i
the vulva, is torn through in fji per cent., whil
of all priniipara; and in 9 per cent, of mu

the penncum, J
ided, and aft»^
:eration of Utj^H

l°7

neum is more or less lacerated. Labor should be a physio-
logical and a natural process, and it seems strange at first sight
that such a process is so often associated with serious damage ti>
the woman. But this is the price that civilized woman pays for
her elevation from the originaL savage state, and the higher or
the more artificial tJie civilization, the dearer the cost, I have
been told by army surgeons that Indian squaws on the plains are
very rarely injured in this way, for with their strong muscles and
elastic tissues, and with tlie smallerfetal head that is the sign of
a lesser mental development of the race, the maternal soft parts
are subjected to nothing like the strain that is put on them in
the case of women bred in towns, ill-developed physically, and
bearing children that spring from a long succession of brain-
workers, and whose heads are extraordinarily large in compari-
son with their bodies. The problem presents itself, tlierefore, to
every obstetrician in every case to avoid this accident if possible,
or, if it must come, to make it as slight in degree as may be.
Although the management of a perfectly normal labor is here
considered, so frequent an accident is laceration of the perineum,
and so constant is the danger of it, that it is necessary to take
up, in this connection, the study of its causes, in order to devise
an effective preventive treatment. The causes of laceration in
the female perineum may in a general way be divided under
three heads : (i) A relative disproportion in size between
the outlet of the birth-canal and any part of the fetus, which
makes the escape of the latter a physical impossibility unless
the aperture is enlarged by tearing its least resisting border;
(2) such a rapid expulsion of any part of the fetal body that
the maternal tissues can not gradually dilate, but give way
before the sudden strain imposed on them ; and (3) any abnor-
mality in the mechanism of labor which pushes the present-
ing part backward against the center of the perineum and
prevents its propulsion forward under the symphysis pubis. In
the first category, relative disproportion, might be put those
cases in which the head is too large or the vulva too small ;
and, further, those cases in which the head presents its largest
instead of its smallest diameters, as happens in insufficient flexion
in vertex presentations. Under the second heading, precipitate
.'Xpulsion, might be put all ca.ses in which the expulsive forces
3 strong ; caaa<^ straight sacrum, in which the fetal head
"""" ' * ind suddenly puts great strain

tin powerful traction is made
1 hi.ad. ;lii Libnormat backward
: placed those ca.ses in
iroximated pubic rami,

308 LABOR AND THE PUERPERIUM.

pushes the head backward and throws a greater strain on the
perineum ; cases again, in which the woman, just as the head is
passing through the vulva, suddenly straightens her legs and
brings them close together ; further, cases in which a straight
sacrum allows the head to descend directly upon the perineum
instead of directing it forward toward the vulvar opening, as a
normally cur\'ed sacrum should do ; and, finally, cases in which
overflexion brings the vertex to bear directly upon the center of
the perineum.

It must appear, from these many different causes, that the
preventive treatment of laceration of the perineum differs con-
siderably in order to meet the diverse conditions that threaten
the integrity of the pelvic floor ; thus, if there is a ver>' great
relative disproportion between the head and the v^ulva and the
opening must be artificially enlarged, instead of allowing the
perineum to tear, perhaps into the rectum, it is better to nick the
margin of the vulva on the side, and allow the tear to occur
where it can not extend too far, and can do no harm. This
simple operation is called cpisiotomy. It should be distinctly
understood that it is called for only in rare and exceptional
cases. Personally, I have no confidence in it whatever, as I
believe it to be based upon an incorrect idea as to the mechanism
of pelvic tears. After the delivery of the child and the placenta
the small wound is to be closed by catgut or silkworm-gut
sutures. If the danger to the perineum comes from a precipitate
expulsion of the head, the proper preventive treatment is a
retardation of labor, either by holding the advancing head back
with the hand or with the forceps, by giving an anesthetic to
control the voluntar>^ muscles, or by administering chloral, which
lessens the force of both involuntary^' and voluntary muscles. If
there is some vice in the mechanism, as overflexion or extension,
it may be corrected by the forceps. It is evident, therefore,
that no one single plan of preventive treatment, no one inflexible
method of ** supporting the perineum," as it is called, will avail
in all cases.

There is, however, a routine practice directed against the
commonest cause of ** lacerated perineum " that will often prevent
a laceration, and will at least keep any one individual's record
down to the proportion already given as the average, and will,
moreover, almost surely prevent a very extensive tear, say, into
the rectum. There are excuses for the lesser grades of lacera-
tion, and it is true that no physician, be his skill what it may,
can absolutely avoid this accident ; but a complete destruction of
the perineum, a tear throu^^h the rectum, is rarely justifiable. It
is most frequently the result of some blunder, carelessness, or
error of technic.

LABOR. 309

As the head distends the vulva almost to the utmost, it fails
to recede as it has done after the previous pain, but remains in
view until the next uterine contraction, which, with the abdominal
contraction that accompanies it, suddenly expels the head through
the widely stretched external outlet. The expulsive force acting
suddenly and being much greater than is necessary to overcome
the slight resistance now offered by the soft parts, lacerates
the tissues instead of dilating and stretching them, as would
happen were the expulsion of the head more gradual, less rude
and sudden. This being the most frequent cause of lacer-
ated perineum, it is easy to devise a means to meet and over-
come the difficulty. The main requirement is to regulate the
expulsive force so that it is just sufficient to overcome the slight
resistance offered by the distended perineum, and as an auxiliary
measure to restrain the progress of the head should this force
become too great or be exerted too suddenly. It is obvious
that one can not govern the force of the uterine contractions,
which are involuntary ; it is just as plain that one can regulate
the force and duration of the abdominal contractions by appeal-
ing to the woman's will. Thus, the physician can call upon her
to strain forcibly or gently, as the case may require, bringing
into more or less active play the expulsive action of the abdom-
inal walls ; he can command her to stop straining, or to open
her mouth and breathe rapidly, which amounts to the same thing,
thus inhibiting the greater part of the expulsive force ; or, if a
powerful uterine contraction should come on, or if the woman
should exert her voluntary muscles too violently, or should fail
to obey the command to stop straining, the expulsive forces
may be neutralized simply by making such firm pressure against
the child's head with the hand that it will not budge. At the
same time the outspread hand, which can most conveniently be
used for the purpose, is applied to the distended perineum so
that the thumb and forefinger encircle the posterior commissure
of the vulva. This hand helps to flex the head when the.
occiput is anterior ; it restrains the progress of the head, and it
pushes it forward under the arch of the pubes, away from the
overstretched muscle of the pelvic floor. This is the best plan
of supporting the perineum, as it is called, though it is not really
a support of the perineum at all, but a diminution of the ex-
pulsive forces and a regulation of the progress of the fetal head,
which is supported, restrained, and directed by pressure, partly
through the perineum, partly directly upon the head itself

Presuming that these precautions have been successful, that
the perineum has been safely retracted over the child's head,
and that the head is born, the face at first appears white, but

3IO

LABOR AND THE PUBRPJIRIVM.

almost immediately turns quite purple and looks as if the child
must be choking to death. It is, as a rule, however, in no seri-
ous danger. The head being the only part of the fetal body free
from pressure the blood is determined to it, and is prevented from
returning freely by the pressure about the neck, thus giving
the child's head, as it protrudes from the vagina, a most alarm-
ing appearance of deep asphyxia. There is, however, in some
cases, a more serious element in the asphyxiated look of the
child ; in one out of four labors the cord is found coiled about
the child's neck, usually only once, and that lightly, but occa-
sionally many times, nine coils having been recorded in one

case, and so tightly occasionally as to completely strangulate the
infant, not by pressure upon the neck, but upon the cord. This
anomaly occurring so frequently, and having such serious results,
must always be borne in mind, and as soon as the head is bom
and ihe neck becomes accessible the medical attendant must at
once ascertain whether the cord encircles it or not, by sweeping
a forefinger between the child's neck and the maternal symphysis.
If the cord is found in this situation, it should be gently
pulled upon, and whichever portion yields should be drawn out,
so enlai^ing the loop that it may be slipped over the head ;
or, if that is impossible, making the loop at least large enough

LABOR.

311

to allow the shoulders to pass through ; or if that, again, is not
feasible, if the cord so firmly constricts the child's neck that the
loop or loops can not be loosened, it may be hastily ligatured
with a double thread and then cut between the ligatures. The
child, in such a case, must, of course, be extracted immediately,
else it will be fatally asphyxiated.

The cord not being felt, or having been attended to, if found
around the neck, the physician next turns his attention to the
child's head. The head is protruding from the vulva, the face
is swollen and almost purple, looking as if the only hope for the
fetus lay in speedy delivery ; the labor is almost concluded, the
medical attendant sees his anxiety and attendance almost at an
end, and for all these reasons, especially if he is inexperi-
enced, he feels strongly impelled to terminate a process that
seems to endanger the fetus, that has caused his patient much
suffering, and himself, perhaps, fatigue, by pulling on the head
and rapidly extracting the fetal body. If he does so, however,
the shoulders hastily pulled through the vulva will almost
surely lacerate the perineum, perhaps deeply. Many a case of
lacerated perineum, even into the rectum, is explained in this
way. A still more serious consideration is that immoderate
traction upon the head may seriously injure the child's spine and
the spinal column. As experience has shown that the fetus is
not subjected to great danger in this situation, and as premature
efforts to extract it entail upon both woman and child a danger
more imminent than that which it is endeavored to avert, it is
better to do nothing at this stage of labor but simply to support
the head upon the hand, waiting for the action of the natural
expulsive forces, which will rotate the shoulders, and with them
the head, and shortly after expel the rest of the body. The
physician may, if he chooses, stimulate the uterus to act by rub-
bing or kneading it, and, as it begins to act, may assist its con-
tractions by pressure upon the abdominal walls over the fundus.
This is all the assistance that need be offered in a natural case.
With this slight addition to the natural forces the shoulders
descend and rotate ; the anterior shoulder slips out first under
the symphysis pubis, the posterior shoulder and arm quickly
follow, the anterior arm then emerges, and, the shoulders being
born, the rest of the body \?> immediately expelled so rapidly
that it is difficult to follow the mechanism of its expulsion. The
moment the child escapes from the birth -canal it emits a lusty cry,
which is usually synchronous with a sigh of intense satisfaction
from the mother, who has in an instant been entirely relieved
of long and intense suffering, and in whom the passive pleasure
of relief from great pain is so great as to become a positive en-

3 1 2 LABOR AND THE PUERPERIUM.

joyment. There are now two patients on the physician's hands
at once, and, although he must in practice devote his atten-
tion to both equally and at the same time, it is more conve-
nient here to consider their management separately. Although
the child's expulsion from the mother gives her such immense
relief, it by no means terminates the labor nor brings her an
immunity from all danger ; indeed, the chief, the most common
danger of parturition, hemorrhage, may be said to begin with
the expulsion of the child, and sometimes a most difficult and
dangerous complication of labor, adhesion of the placenta to the
uterine wall, only manifests itself after the complete escape of the
child from the birth-canal. There are, therefore, two problems
with which to deal in the third stage of labor in almost every
case, no matter how normal it may appear, — the delivery of the
placenta and the prevention of hemorrhage. As hemorrhage
may occur before the expulsion of the placenta, and therefore
stands first in point of time ; as this accident is of the gravest
nature and its prevention of the greatest importance, the first
thought of the medical attendant should be the routine means to
adopt in every case to prevent its occurrence.

Provided the uterus contracts and remains contracted, the
enormous blood-vessels in its walls are obliterated and hem-
orrhage is impossible. On the other hand, if the uterus remains
flaccid and uncontracted while the placenta is being separated,
or if the organ, at first contracted, afterward relaxes, hemorrhage
of the most alarming character must as necessarily occur.

The whole problem, therefore, of preventing hemorrhage
after delivery resolves itself into a problem of securing and of
maintaining uterine contraction. Luckily, nature takes this task
off our hands in a vast majority of cases. In a healthy, vigorous
woman little concern need be felt in regard to the action of the
uterus ; its muscular fibers contract firmly ; its whole body
assumes a solid, hard consistence, and there is no hemor-
rhage. Unfortunately women who have lived in the midst of
an artificial civilization, who are often of an enervated habit and
imperfect physical development, in whom a natural process re-
quiring vigorous muscles does not always run a natural course,
are more or less prone to bleed after labor, and, therefore, one
can never afford to be remiss in his efforts to prevent relaxa-
tion of the uterus after confinement, never knowing surely in
whom it mav or may not occur.

Finn Contraction of the interns After Labor is Secured dv Ex-
ternal and by Internal Stinndi to Contraction. — The latter con-
sists of a dram dose of the fluid extract of ergot in a little
water, administered as soon as the child's body is born. The

LABOR. 313

former consists of manipulation of the uterus. Luckily the uterine
muscle is irritable, and shows its irritation by contracting its
fibers. Luckily, again, it is accessible. One can easily grasp
it through the abdominal walls ; can rub it and exert direct
pressure upon it, these actions exercising a powerful irritant in-
fluence upon the uterus and bringing about, in the ordinary case,
firm contraction. This is the most efficient, readily applied ex-
ternal stimulus to uterine contraction, and one that must be in-
variably applied, and that, too, continuously from the moment the
infant's body is expelled until a milder fonii of external stimulus
which is to maintain uterine contraction is adjusted, — the obstet-
rical binder. The moment that the child escapes from the woman's
body the physician or nurse seizes the uterus through the ab-
dominal wall and exerts constant pressure upon it, irritating it
still more from time to time by a kneading or a rubbing motion.
If the woman is fortunate enough to have a good nurse, this
duty may safely be left to her, while the doctor washes his hands
and takes a brief rest. Some fifteen minutes having elapsed, the
placenta being delivered, the woman having been cleaned and
made more comfortable, the constant pressing and kneading of
the uterus may be replaced by the more gentle and more con-
tinuous external stimulus of the binder and abdominal pad.
This binder holds an important place in the treatment of Eng-
lish-speaking women at least. In some civilized countries it
is not used at all, and, it must be confessed, it is unneces-
sar>% from the medical point of view, after the first twenty-
four hours.

The obstetrical binder, however, adds greatly to the woman's
comfort by maintaining the intra-abdominal pressure and thus
preventing cerebral anemia. It undoubtedly prcser\^es the
figure, — a fact to which no woman is indifferent, — and it de-
creases the danger of postpartum hemorrhage by maintaining a
tonic contraction of the uterus. For all these reasons the use
of the obstetrical binder is well justified — is, in fact, demanded —
in the intelligent management of the puerpera. The best binder
is a piece of unbleached muslin, about a yard and a quarter long
and wide enough to reach from the trochanters to the floating
ribs. It is pinned together from above downward, and is made
to fit more snugly and comfortably by making gores at the sides
above and below the hips. The pad should consist of one or
two folded towels put abcn'C t/ie navel to fill the hollow in the
epigastrium left by the evacuation of the womb and its reduc-
tion in size.

The second problem of the two that confront a physician in
the management of the woman in the last stage of labor is the

314 LABOR AKD THE PVERPERIUM.

delivery of die placenta. To superintend this process intelli-
gently it is necessary to recall the chief phenomena of the
mechanism of the third stage of labor.

The placental structure resembles nothing so much as a
sponge, and as the uterine wall contracts and retracts, the
placenta follows the reduction in the size of the placental site
by a corresponding reduction in the placental area, up to a cer-
tain point. The placenta diminishes
in size until all its villi come in ac-
tual contact with one another; until,
instead of being a spongy organ
with the intervillous blood-spaces
separating the villi from one an-
other, the whole ot^an becomes
a solid mass, and can not accom-
pany a further reduction in the
area of uterine wall to which it is
attached, so that the smallest addi-
tional contraction of the uterine
muscle innst spring off the whole
placental mass at once. This point
is reached when the placenta has
been reduced to about one-half
of its natunil area — a fact that
has been demonstrated on uteri
removed by the Porro Cesarean
section or on postmortem exami-
nations of the organ in patients
who had died during or directly
after labor. As to the expulsion
of the placenta after its detachment.
that is a matter easily understood ;
lying in the uterine cavity as a loose
foreign body, all that is required is
the vigorous action of the uterine
muscle to drive this substance out
of the uterine cavity. But. once
beyond the province of the thick,
muscular portion of the uterus.
above the contraction-ring, there is
no further force to drive the placenta on. for now it rests in the
semiparalj^xed lower uterine segment (see Fig. 1 87). in the
cervix or in the vagina, both, also, in a measure, paralyzed by
the extreme ovcrdistcntion to which they have been subjected,
C' it may rest for hours or days, until it undergoes de-

Fig. 187.— Ui I Bled lower uter-
ine segmeni and cervix nflcc Ubai,
(roiu n froien iecliun (UcDckiser
nnd Hofmeiet),

LABOR. 3 I 5

composition.^ Arguing from the fact that animals never re-
quire an artificial delivery of their after- births, many obstetri-
cians of the last century declared that the delivery of the
placenta should be left entirely to nature. The result was dis-
astrous, as may be imagined.

It is, therefore, a necessary part of the management of the
third stage of labor to secure the separation of the placenta by
stimulating the uterus to contract and by aiding it to expel its
contents by exaggerating its expulsive power. These two
objects are best obtained by what is known as Crede's method,
a method first proposed to the profession in a systematic manner

Fig. i88. — The expression of the placenta.

by the late Professor Credo, of Leipsic,^ in 1861. A somewhat
similar plan had been in use in Dublin for a long time before,
and many primitive and savage people have employed, perhaps
for ages, methods based upon the same principle.

In applying Crede's method the uterus is seized in a grasp
illustrated in figure 259, is kneaded and rubbed until it con-
tracts with vigor ; only then, and only in conjunction with the
uterine contraction, should it be firmly pressed down in the
direction of the axis of the pelvic inlet, while it is compressed
between the fingers and thumb with considerable force. The
placenta is squeezed out as the stone is pressed out of a cherry.
It should be expressed fifteen or twenty minutes after the child
is born. As it slowly emerges from the vulva it should be

* v. Campe (" Zeit. f. Geburtsh. u. Gyn.," Bd. x, H. 2) in 120 observations
found that in 24 instances the placenta had not been expelled in twelve hours.

' ** Monats. f. Geburtskunde," xvii, p. 274.

3l6 LABOR AND THE PUERPERIUM,

caught in the obstetrician's hand, while a nurse holds a basin
pressed close into the mother's lower buttock, to receive the
blood that usually spurts out with the after-birth. The mem-
branes trail after the placenta, running up into the vagina and
the uterine cavity. To extract them without tearing them, and
thus leaving a portion behind, they should be seized between the
whole length of the thumb and forefinger and gently pulled, first
forward toward the symphysis, then backward toward the sacrum,
the uterus meanwhile being allowed to relax. It is a mistake to
turn the placenta over several times to make a " rope '* of the
membranes.

To return, now, to the infant which has just been bom.
The head and shoulders having escaped, the rest of the body
slips out almost immediately, the child's arrival being announced

Fig. 189. — The reception of the placenta in a basin.

usually by a vigorous cry, a purely reflex action caused by the
sudden shock which the new-born experiences on suddenly
emerging from an aquatic existence, in which its immediate sur-
roundings have a temperature of about 99°, into the atmosphere
and a temperature not over 70°. This violent shock produces
not only a spasmodic action of the diaphragm and the muscles of
respiration, but also of the bladder, and of all of the muscles' of
the body as well, so that often urine is voided directly after birth,
and the arms and leg are moved about quite violently. As
soon as the child is born, it is well to see that its air-passages are
clear and not clogged by mucus or blood that might have been
inspired during labor. This is done by crooking the little
fin&rer and introducing it back of the epiglottis ; if, however, the

emits a vigorous cry, it is proof enough that the

LABOR.

317

respiratory tract is not obstructed. The infant is then placed
on its right side, this posture favoring the closure of the foramen
ovale and facilitating the passage of the blood from the ascend-
ing cava over the Eustachian valve into the right auricle. The
position should also be so arranged as to turn the child's face
from the mother's genitals and to protect the infant's air-passages
from the maternal discharges incident to the third stage of labor,
care being taken, also, not to put the cord too much on the
stretch, for all this time, of course, the infant remains attached
to the mother by the umbilical cord. Now arises the question,
in every case, as to the advisability of severing the cord at once
and getting the child out of the way. The placenta, it has been
argued, no longer performs its vital functions ; the child breathes,
and, therefore, it might be better to cut the cord, to remove the
infant from the bed, and to turn it over to the nurse. This plan.

Fig. 190. — The position in which the child should be placed after birth.

however, does not take into account the fact that there remains
a considerable quantity of fetal blood in the placenta ; that it is
an advantage to have all of this blood, if possible, returned to
the infantile body where it belongs, and that, further, the deple-
tion of the placenta renders its expulsion easier. The blood in
the placenta will return to the child's body, if time is allowed
for it ; on the one hand, the action of the respiratory muscle
exerts a suction upon the placental vessels, which aspirates the
blood from the placenta ; on the other hand, the pressure upon
the placenta by the uterus drives the placental blood into the
fetal body. To demonstrate the advantage of late ligation of
the cord, Budin ^ conciucted a series of experiments, with the
following results : the cord ceased beating in 22 cases, on the

^ Pablications du " Progrds Mddical," 1876 ; also *• Obstetrique et Gynegologie,"
x886.

3 1 8 LABOR AND THE PUERPERIUM.

average, in two and one-half minutes. In these cases the average
weight of the placenta was 520 gm. (i| lb.), and the amount of
blood that escaped from the umbilical vein in 20 cases was 92 gm.
(3.2 oz. Avoir.) less in late than after immediate section of the cord.
Thus, by immediate ligation 92 gm. (3.2 oz. Avoir.) of blood
are lost to the infant's body. Moreover, in contrasting the weights
of children after immediate and late ligation of the cord there was a
gain of two to three ounces in favor of late ligation. It is better,
therefore, to wait two or three minutes after the birth of the infant
before cutting its cord. ^ The proper time having arrived, the cord
should be ligated about two fingers* breadth from the child's
body with a piece of stout surgeon's silk, sterilized. The ligature
is tied firmly once around with a double knot. The ends are then
doubled around again and are tied with a single and a bow knot,
so that the nurse, after the child is washed, may slip this last knot

Fig. 191. — Cutting the cord.

and may then retie the ligature firmly. This precaution surely
avoids a primary or secondary hemorrhage from the cord, which
sometimes occurs in consequence of a shrinkage of the mucous
tissue, making the original ligature too loose. The obstetrician
is now ready to cut the cord. The child is slippery and hard to
hold ; its legs and arms are jerked about in a very disconcerting
manner to the beginner, so that carelessness in the use of scissors
at this juncture might result in injur>^ to the fingers, the toes, or,
in the male child, to the penis. The manner of cutting the cord
illustrated in figure 191 surely avoids all such accidents. The

^ There has been a g(X)d deal of criticisni upon Budin's projxjsition to ligate the
cord late ; several German authors lia\ e attril)iited a number of infantile complications
to it. I have carried out the practice for ten years, and have convinced myself by
experience of its advantages.

LABOR, 319

child's connection with its mother being severed, it is wrapped in
a blanket ready to receive it and is put in some safe place, where
it will not be trodden nor sat upon. Its own crib is the best
place for it. The cut end of the cord attached to the placenta is
not tied, but is allowed to drain into a basin, so as to lessen as
much as possible the bulk of the placenta. In case of twins,
however, a double ligature on the cord is required, else the
second child might bleed to death on account of anastomosis
between the vessels of the placenta.

CHAPTER II.

The Ptierperal State*

The moment that labor terminates with the expulsion of the
placenta, there begins an efifort on the part of nature to restore
to their normal condition those organs and systems that have
been in an active state of development for nine months before ;
there is destroyed in a few weeks that which it has taken months
to build up, and side by side with this destructive process goes
on with equal rapidity one of growth and repair. One sees the
reduction of the sexual, the circulatory, and the nervous systems
to their normal capacities and functions by the destruction of
redundant material ; but one sees with this the reparation of the
injuries of child-birth, the formation of a new endometrium, and
the rapid development of an entirely new and complicated func-
tion, lactation. And yet, by a provision of nature which is almost
beyond comprehension, these two opposed processes of decay
and regeneration go on at the same time in one body, involving
whole systems and organs, without manifesting themselves in
the slightest derangement of the individual's health. Under no
other circumstances could an organ weighing two pounds, and as
large as the liver, degenerate and in great part disappear without
the gravest symptoms of constitutional disorder. In no other
condition could the whole composition of the blood be materially
altered ; the heart changed in size, power, and capacity ; the
nervous system modified in sensibility ; a large body-cavity,
stripped of its mucous membrane and again resupplied with a
new lining ; large organs, as the breasts, suddenly assuming
great functional activity, without very marked evidence of dis-
ease ; and yet in the puerperal state there are all these remarkable
changes while the woman in appetite, feeling, and temperature is
in perfect health. But it is obvious that in a condition which,

320 LABOR AND THE PUERPERIUM,

though it is called physiological, borders so closely on the
pathological, very little is required to pass the boundary-line
into disease. Anomalies of excess and deficiency in the natural
processes occur easily ; the raw surface of the uterus with
the wounds of the vagina and vulva give ready entrance to
infectious poisons, and the whole individual seems especially
sensitive to unfavorable external influences, both mental and
physical. Consequently this is the period in the history of the
child-bearing woman that is most beset with difficulties and
dangers and most likely to be marked by accidents and com-
plications. The preventive and curative treatment of these com-
plications is one of the most difficult tasks in obstetrics, and
success here, as elsewhere in medicine, depends to a great extent
upon a thorough knowledge of the natural process, for only on
such knowledge can one base a rational management of the
normal case and a satisfactory treatment of the abnormal con-
ditions which are so apt to develop during the puerperium.

The puerperal state, or the puerperium, comprises the time
from the termination of labor until the uterus has regained its
natural size. This is a period, in the normal case, o{ six weeks, ^

The study of the physiological phenomena in the puerperium,
or puerperal state, involves a study of the reduction of the uterus
directly after delivery to the uterus of the healthy non -pregnant
woman, — a process called technically ** the involution of the
uterus " ; it involves a study of the involution of the vagina, of
the destruction of the deciduous mucous membrane, and the
regeneration of the endometrium ; of the retrograde changes that
occur in the uterine ligaments and peritoneal covering and in the
ovaries ; of the alterations by which the blood and the heart
regain their normal condition and the changes in the pulse ; of
the changes in the body- weight, the temperature, the skin ; the
action of the bladder and of the alimentary canal. An important
factor also in the puerperium is the establishment of the milk
secretion.

The Involution of the Uterus. — Three theories may be
advanced to account for it: (i) A fatty degeneration of the
muscle-fibers and the absorption of the fine granular fat-globules
to the complete destruction of the uterine muscle, its place being
taken by a new growth of muscle-fibers developed from the
embryonal musclc-cells in the outer layers of the uterine mus-
culature. (2) A partial degeneration and an atrophy of the large

* The word puerperium comes from pucr, a child, and parioy to bear, and
denoted, in the original Latin, the child-bed period, the lying-in period; so it is an
aDDroDriftte term to designate this one of the four periods in obstetrics, — pregnancy,

nm. and lactation.

THE PUERPERAL STATE. 3 2 1

muscle-fibers seen in a pregnant uterus at term. (3) The con-
version of the muscle-cell contents into a peptone, its absorption
into the blood-current and discharge through the kidneys, giving
rise to the peptonuria of puerperal women (Fischel).

Kilian,^ in his examination of rabbits* uteri thirty to thirty-
six hours after they had expelled their young, found fat-globules
in the epithelial covering of the uterus, noticed that the muscle-
fibers looked fainter and paler than in pregnancy, and saw in
their interior very fine, shining fat-globules ; alongside of these
degenerated muscle-fibers Kilian found some quite young fibers,
as he had seen them in the uteri of young animals. HeschP
confirmed Kilian's observations, and went even further in de-
claring that the muscle-cells were completely destroyed by fatty
degeneration ; this writer saw, in the outer portion of the uterine
body, at first nuclei ; which, developing cell -contents around
them, gradually transformed themselves into typical unstriped
muscle-fibers. Thus, after labor the uterine muscle was destroyed
and a new development of muscle-tissue occurred to take its
place. Robin, ^ on the other hand, claimed that the involution
of the uterine muscle is essentially atrophy of the individual
muscle-cells. Kolliker* says that the involution of the puerperal
uterus consists of a diminution in the size of the contractile
fibers in the muscle-layer, alongside of which may be seen fatty
degeneration. Mayor, ^ from a study of fourteen specimens
dating from the first day after delivery until the ninth month of
lactation, concludes that, while the fatty degeneration of the
muscle-fibers is more pronounced than Robin thought, it is far
from having the importance that Hcschl attributed to it ; it does
not seem, as this author believes, to cause the destruction of the
muscular elements. Mayor, therefore, attributes to atrophy the
predominant role in the involution of the uterus. Winckel® still
holds that the reduction of the puerperal uterus is due to fatty
degeneration. Sanger, '^ from the observ^ation of twelve uteri
obtained at periods varying from four hours to fifty-five days
after labor, recognizes the fatty degeneration in the muscle-cells,

* ** Die Structur des Uterus bei Thieren," Henle u. Pfeuffer's " Zeits. f. ration-
elle Medicin," 149 u. 1850, Bd. viii u. ix.

' *' Untersuchungen iil>er das Vcrhalten des menschlicben Uterus nach der
Geburt.,'* " Zeits. der k. k. Gesellscbaft der Aerzte in Wien," 1852, viii, 2.

* " Diet, encycl. des So. m6d.," 2e serie, t. x, p. 14.

* ** Gewebelebre," 5. Aufl., p. 565.

* ** Etude bistologique sur I'lnvolution uterine," ** Arcbives de Pbysiol. norm, et
path.,'* ix, X, 1887, p. 560.

« *« Lebrbuch der GeburtsbUlfe," 1889.

» Abst. in Scbmidt's •« JabrbUcber," No. 3, 1888, p. 250.

322

LABOR AND THE PUERPERIUM.

but does not believe that they are destroyed.^ Microscopic
sections of five uteri in my possession, obtained respectively in
the last week of pregnancy, two hours, thirty-six hours, seventy-
two hours, and seven days after confinement, indicate that
fatty degeneration plays a most important part in the reduction
of the large muscle-celis characteristic of pregnancy to the
much smaller muscular fibers of the unimpregnated uterus. My
own belief is that the redundant material within each cell is

Fig. 192 — fl, Ulerine muscle-fibers nine days postpartum;
fibers eigbt days postpartum ; c, uterine muscle-libers in tbe eighlh monlh of
pregnancy-

destroyed by some degenerative process (chiefly fatty), but that
the cell is not destroyed in Mo. Measurements made by Sanger'
show plainly that the reduction of the uterus after labor is

' — ■ tlut "the fat-globules aad other degeneralion products do tint

1 drcuiBtion, liul are oxidiici on the spot. There is no such

*" ("Die RUckbildung der Muscularis der puetperalen

THE PUBRPEHAL STATE.

323

effected by a diminution in the size of the individual fibers, and
not by their destruction. '

There is a greater unanimity of opinion in regard to the invo-
lution of the serous covering, connective tissue, blood-vessels,
and mucous membrane of the puerperal uterus.

Mayor ^ found, in the peritoneal covering of the uterus after
delivery, a number of folds in the membrane ; at the bottom of
these folds the endothelial cells seemed to be transformed into a
spherical shape. Kilian * found the cells in Ihis region infil-
trated with fat-globules. Bernstein,* in a study of involution in
the rabbit's uterus, paid especial attention to the behavior of the
connective tissue. He found that the reduction of this tissue in
the puerperal uterus was effected by a fatty degeneration of the
connective -tissue cells, and by a drying out, as it were, of the
connective-tissue fibers ; these, deprived of the excessive blood-

fig- !■).;■

i( tlio prcgtian and o he uerpero i

supply of pregnancy, dry up and si r nk Bernste n nc dentally
mentions the fatty degeneration of the peritoneal endothelium,
and expresses the opinion that the muscle-cells, while they do
undergo a fatty degeneration, are not completely destroyed.

The chief changes in the blood-vessels seem to be shrinkage,
the obliteration of many large vessels by a connective-tissue
growth in the intima, associated with fatty degeneration of the

' FibCT-length in pregnnnl ulcnis

" •' in firat few hours postparluni , . . . .

" ■> uDlil Ibe Tonrlh Hay po3t[ttttum . . .
" " in fiw hnlf qf Mconii week pwtpRiium .
" " in bepnninB: of third weelt postpartum .

'* " St end of llftii week posljurtum . , . .

" Ein Bcitng nir Lehre von der puerpenlen Iniolulion dcs Ulcnu,"

324

LABOR AS'D TUE PUERPERIUM.

media,' and the development in tlie adventJtia of the vessels not
obliterated of new elastic fibers.

The involution of the endometrium is now clearly under-
stood, thanks to the investigations, first, of Friedlander,^ then
of Kundrat,* Engelmann,* l-anghans,^ Leopold,^ and others.
When the ovum is cast off at term, it carries with it, in the
strictly normal case, the whole ovular or cpichorial decidua and

Fig. ty4. — Lotliiu on the aecoiiil
day (lochia cnipnia], showing a few
cocci and slreptncocci : a, Dccidiul
cells J b. reil Iilcx»d-corpuscles ; e,
wliite blood -corpuscles ; d, cpiihelitun
(Winckel).

95. — Lochia on the fourth
day: rt. Decidual celU; *. while bl«>d-
corpuscles; r, a few red blood -corpus-
cles : >/, epiibelimn ; e, micro-orcBiiisins
(Winckel).

Fig. 196. — Locbii on leventh day; afebrile case: a. Rlood-corpuscles ; *. dijilo
CMci and inonococci; <-, while blood-coipuscles 1 d, eplibelium ; t, deuduai celU
(Wmckel).

the upper cellular layer of the uterine decidua, leaving behind on
the uterine wall the lower cellular layer and the glandular por-
tion of the uterine mucous membrane. This membrane, deprived

•Ha Verballen dcr BlulgenLific ivn Litems nocli stniigehabiei

." W. XV.

tleisochungenllbcriicn L'tenis." tjjpsic, 1870; " Archi»

«." 1873. • m.u

Bl. • /*.,/, Bd. xii.

THE PUERPERAL STATE. 325

in great part of its nutriment by the contraction of the uterine
wall and the obliteration of many of its blood-vessels, loses its
vitality in that portion furthest removed from its source of nutri-
ment— the superficial layer of decidual cells. These die and are
cast off with the lochial discharge in a condition of fatty degen-
eration or disintegration. By the shedding of these cells the
glandular layer of the decidua is laid bare. Now the involu-
tion of the endometrium ceases and a regeneration of the
membrane begins. The epithelial cells within the glands take
on an active growth and reproduction ; the interglandular con-
nective tissue shares in the new development ; by its growth it
rises in embankments between the glands, making them deeper,
and so in time reproduces the characteristic utricular glands of
the uterine mucous membrane. This process requires some time.
Mayor says : ** On the twenty-fourth day after delivery I have
not found glands in the region of the placental insertion. The
mucous membrane, although reconstructed at the second month,
is then furnished with fewer glands, less regularly disposed, and
of a greater caliber than in the normal state."

The uterus is not the only organ of the sexual system that
exf)eriences a retrograde change after labor. The ovaries and
tubes, the broad and round ligaments, the pelvic connective
tissue, blood-vessels, and lymphatics, all undergo modification.
That portion also of the birth-canal — ^the lower uterine segment,
the cervix, the vagina, and the vulva — which is dilated to an
extreme degree to allow the passage of the fetal body, must
likewise exhibit rapid involution to regain its wonted tone and
caliber. In these structures the process is mainly one of retrac-
tion of overstretched tissue ; but there is, in addition, a certain
amount of degeneration and atrophy of the redundant cells that
the increased blood-supply and increased stimulus to growth of
pregnancy called into existence. Particularly is this true of the
lower uterine segment and cervix, which in their involution dis-
play an intermediate process between that by which the reduc-
tion of the uterine body is effected and that by which the lower
jx)rtion of the parturient tract regains its normal state.

The involution of the uterine adnexa progresses satisfac-
torily if the uterine involution itself is normal. The reduction
of the overstretched vagina and vulva is sure to occur if these
parts have not been seriously lacerated, although, like all over-
stretched muscular canals, they never quite return to their
original caliber.

From the large sinuses at the placental site, laid bare after
the separation of the placenta ; from the innumerable little ves-
sels of the decidua that have been torn in the separation of the

326 LABOR AND THE PUERPERIUM,

ovum from the uterus ; from the rents of various degrees that
have been made in the cervix, vagina, and vulva during labor, it
is inevitable that there should be, for some time after delivery,
an oozing of blood in considerable quantity. As the residue of
the decidua and the blood-clots remaining in the uterine cavity
are disintegrated, the products of this decomposition must also
escape externally. And as the whole genital canal, lined by a
mucous membrane, is stimulated and irritated by foreign sub-
stances and a large blood-supply, it is obvious that the mucous
secretion of the genital tract will be considerably increased, and
must make its escape also from the vagina. This composite
discharge after labor, made up of blood, degenerated epithelial
cells, the debris of disintegrating animal material, mucus, and
large quantities of harmless micro-organisms, is called *' the
lochia.'* ' It is important to appreciate the normal character of
this discharge, for changes in its quantity, odor, or constituent
parts often point to some morbid process. The older writers
on obstetrics paid great attention to this feature of the puerperal
state, and gave to the discharge three names, which indicate the
three changes that it undergoes in appearance. For the first
five days it is called lochia rubra ; for the next two days, lochia
serosa ; and after that, lochia alba. At first, as might be ex-
pected, the discharge is almost wholly bloody — the lochia rubra.
As, however, the repair of the injuries of parturition progresses
and the hemorrhage ceases, the discharge is the result simply of a
serous exudation and a species of catarrh affecting the mucous
lining of the genital tract — the lochia serosa. Soon, however,
the dead tissue in the genital canal is cast off; disintegrated and
fatty epithelial cells are mixed in the discharge ; micro-organisms
are found in it, while the pus from the granulating wounds all
along the genital tract forms an important constituent of the
discharge after the sixth or seventh day. To the lochial dis-
charge at this period is given the name lochia alba, — appropri-
ately enough, — for it looks like, and is, practically, healthy pus.
The last stage of the lochial discharge lasts from the seventh
until the tenth, twelfth, or fourteenth day, or even longer. Two
other features of the lochial discharge are also of clinical inter-
est— the quantity and the odor. The amount of discharge at
the three different periods may be expressed scientifically thus :
During the first four days the amount of discharge is i kilo-
gram, or 2.2 pounds ; during the next two days, 280 grams, or
about 10 oz. Avoir.; and until the ninth day, 205 grams, or about
7 oz. Avoir., the entire loss amounting to 3 ^ pounds. These

nf no value to the practical clinician.

Greek 'k6x<Ky pertaining to a woman in child-bed.

THE PUERPERAL STATE. 327

No physician in private practice can accurately measure the
amount of lochial discharge ; so that the convenient method of
estimating it has been adopted of noting the number of napkins
or pads that are soiled in the twenty-four hours. The normal
puerpera should not require a change of the vulvar pads oftener
than six times in the twenty-four hours for the first four or five
days. The importance of being able to distinguish between a
normal and abnormal amount of lochial discharge is obvious.
Without this ability on the physician's part a dangerous hemor-
rhage might go undetected, or a marked diminution or even
suppression of the lochia might be unnoticed.

The odor of the lochia during the period of sanguinolent
discharge is very much that of fresh blood or raw meat. Later,
when the mucous secretion forms a considerable part of it, the
predominant odor is that peculiar to the secretion from these
parts. Should there, however, be retained within the uterus,
unusually large masses of decidua, placenta, membranes, or blood-
clots, and should the germs of decomposition gain access to
these highly putrescible bodies in a situation most favorable to
their decomposition, the lochia at once takes on a putrid odor.
This is frequently the first danger-signal that the uterus has
become the seat of a process which places the woman's life in
constant peril. It is none too pleasant a duty this, of investi-
gating the odor of the lochia, but an examination by the sense
of smell of the napkins that have just been removed forms an
important part of the duties of the physician at every visit until
the discharge has almost ceased.

The involution of the uterus has been described as if it were
one continual process, moving on evenly from beginning to end.
But as the involution of the uterus depends primarily upon the
contraction of the muscular fibers in its walls, one might cor-
rectly infer that this process is not one of smooth and even
progression, but that it might be indicated graphically by a
series of waves, representing contractions of the uterus of more
or less force and frequency and intermissions of less firm con-
traction ; the retraction of the uterine muscle, however, main-
taining fairly well what is gained by contraction. Each case
has a certain degree of individuality ; in one the contractions
are firm and the intervals between them short ; in another
it is the reverse and all gradations may be found between the
extremes ; but while there are in every case individual pecu-
liarities, the action of the uterus after labor is governed by a few
general laws. Thus, in primiparae, the uterus being more
powerful, better supplied with muscular tissue than it will ever
be again in a subsequent confinement, contracts so vigorously,

328 LABOR AND THE PUERFERWM.

relaxes so little, that after the expulsion of the placenta the
uterine cavity is almost obliterated, and the amount of bloody
lochia is reduced to a minimum. On the other hand, in mul-
tipar.T, the uterine muscle beinjj in some degree weakened by
stretching and perhaps by some destruction of muscle-substance
that has occurred in previous prefjnancies, the uterus after labor
does not contract so firmly and the relaxations between the
contractions are greater in point of degree and duration. More-
over, when the uterine muscle has been overstretched, as it is
in plural pregnancies or in cases of hydramnios, or when the
labor has been exceedingly long or unusually precipitate, very
firm contraction does not appear after labor and there are apt to
occur period* of over- relaxation. This condition, in civilized
women, is so very common that it is necessary to study it under
the head of the physiology of the puerpcrium, and yet the
consequences of a failure on the part of the uterine muscles
to contract with maximum intensity after labor are always un-
pleasant, and may be disastrous. A relaxation of the uterine
muscle-fibers implies a loosening of the countless living ligatures
that bind the large vessels of the puerperal uterus. The imme-
diate effect is an escape of blood into the uterine cavity. Oozing
out gradually from the imperfectly closed blood-vessels .and
sinuses, and, finding space in the enlarged uterine cavity to
collect, it forms clots often of considerable size, which act upon
the uterus, like any foreign body in it, as an irritant, exciting
it to active contractions which only cease when the foreign
substance is expelled. These active contractions of the uterus
are always painful, with a pain like that of a cramp in any
muscle.

These painful contractions, affecting the uterus after delivery,
caused primarily by lack of firm contraction, and immediately by
the presence of clot.s of blood in tttcro, are called, appropriately
enough, after-pains, — the painful contractions of the uterus after
labor. For the reasons already given tlicy are not experienced
by primipara; unless the uterus has been unduly distended or the
labor has been too prolonged or too precipitate. On the other
hand, they are a constant phenomenon in multipara, and the
physician's treatment of them constitutes almost always a part
of his routine management of the puerperal state in such
Apparently a trifling matter, it is really one of con-
In the first place, the pain is sufficiently
", but, more important still, these after-
d physician, the presence within the
r putrescible material ; and until
IBS is inditced to remain in a state

THE PUERPERAL STATE. 329

of firm contraction, the woman is not entirely safe from the
dangers of septicemia. And, moreover, it is necessary to be
familiar enough with the clinical features of after-pains to be able
to distinguish them from the pain of peri-uterine inflammation,
which often denotes the onset of septic infection. It should not
be difficult to do this. The intermittent character of after-pains ;
their cramp-like nature ; the fact that pressure does not increase
the pain, and that the pulse and temperature are unaffected,
suffice to distinguish the painful contractions of the uterus after
labor from the pain of inflammation.

The appropriate treatment of after-pains is suggested plainly
by what has been said as to their cause and nature. It
consists of the administration of ergot to stimulate vigorous
contraction and firm retraction of the uterine muscle, and
opium to diminish the pain of the contraction. A mixture of
fluid extract of ergot and paregoric is a useful prescription,
though, in cases of extreme pain, ergot by the mouth and
morphin hypodermatically give a better and quicker result.

Although the most remarkable changes that occur in a
woman's organism after labor are seen in the genital organs,
the whole body undergoes a modification. The respiratory,
circulatory, nervous, and excretory apparatuses are affected, with
accompanying peculiarities of respiration, pulse, temperature,
weight, the excretion of urine and sweat, and the evacuation of
the bowels, while the nervous system shows a gradual change
from the nervous irritability characteristic of pregnancy to the
degree of equanimity that the individual may have before pos-
sessed.

Alterations in the Circulatory Apparatus of the Puerpera.

— ^The pulse of a woman during labor is rather rapid, full, and
bounding ; directly after delivery it becomes pretematu rally slow ;
if the individual's normal pulse-rate were 70 to 80, it might,
during labor, rise to 90, but directly afterward it sinks, perhaps,
to 60 or even lower. It is occasionally as low as 40 in a perfectly
healthy young woman. In looking for the cause of this altera-
tion in pulse-rate one must recall the influence of gestation
upon the heart and the alterations in the constitution of the
blood during pregnancy. The whole volume of the latter is in-
creased, but not by an equal increase of all the constituent parts ;
the corpuscles are relatively decreased in proportion to the
liquor sanguinis ; the watery element of the blood is propor-
tionately increased, making the condition of the blood during
pregnancy one of hydremia. There is a relative decrease of
albumin, blood-salts, and the percentage of hemoglobin, a relative
increase of the fibrin-making ferment Expressed definitely, this

330 LABOR AND THE PUERPERIUM.

decrease is to the extent of about 700,000 red blood-coqjuscles
per cubic millimeter and about eight per cent, of hemoglobin.
Within the first twenty-four hours after labor the decrease in
red blood-corpuscles and hemoglobin is yet more marked, on
account, no doubt, of the escape of blood in the third stage of
labor and immediately after it. But after the first twenty-four
hours the blood begins to recover its normal constitution, and at
the end of two weeks it is so far on the road to perfect involution
that it is much nearer a normal condition than it was in the latter
half of pregnancy, although it is still somewhat deficient in red
blood-corpuscles and in hemoglobin.

These changes, however, do not explain the cause of a slow
pulse in the puerperal state : it is discovered in the heart. It
has long been believed that the area of cardiac dullness is in-
creased in pregnancy, and that there is a hypertrophy of the
walls of the left ventricle. As the whole volume of blood is in-
creased in pregnancy, and as additional resistance to the circula-
tion is offered by increased intra-abdominal pressure and by direct
pressure of the uterus upon the pelvic vessels, it is reasonable
to assume that the heart, in addition to being hyf)ertrophied, is
also dilated. The additional force and capacity of the heart is
acquired to meet the additional demands of pregnancy: A
greater volume of blood is propelled through the vessels by an
enlarged and strengthened heart, beating with a normal rapiditv.
Labor comes on, the uterine cavity is emptied, and suddenly
the increased vascular power has become unnecessary if not
dangerous. The amount of work done by the heart \s repre-
sented by two factors ; the rapidity plus the strength of the beat
and the power of the heart can be lessened by diminishing either
one of these factors. It is obvious that the increased power of
the hypcrtrophicd heart-muscle can not be abrogated in a
moment. It is equally obvious that the other factor in heart-
power can be modified at once to suit the new and lesser
requirements. And this, probably, is the method nature adopts to
avoid excessive heart-action and an excess of blood in inif)ortant
organs after labor. The heart -beats are reduced some twenty
to thirty in a minute.

Changes in the Urinary System After Labor. — ^The phy-
sician is often annoyed in obstetrical practice to find that many
women after labor are unable to empty their bladders and con-
sequently require the use of a catheter, which must be employed
in the majority of cases by the physician himself, especially in
country practice.

To comprehend the changes in the urinary system it is
necessary' again to revert, for a moment, to pregnancy. The

THE PUERPERAL STATE. 33 1

main changes in the kidney, bladder, and urine in that condi-
tion may thus be summarized : The kidneys, by reason of addi-
tional supply of blood and extra work to do, are hypertrophied ;
the urine is increased in its aqueous element, diminished in
solid constituents, except chlorids. The bladder, in pregnancy,
from the pressure of the gravid uterus behind, is unable to
expand in a normal manner, but must accustom itself to a
distention, chiefly upward. When the uterus is empty and
has shrunk to half its former size, the bladder has room at
once to distend in all directions, and can thus hold a very
large quantity of urine before its walls are subjected to the
same degree of tension to which they were accustomed dur-
ing pregnancy. Thus large quantities of urine may collect
before there is a disposition to urinate. Moreover, the abdomi-
nal walls, so long kept on the stretch, are suddenly released
from the intra-abdominal pressure, and do not for some time
regain their tone ; so that the action of the abdominal muscles,
which are, perhaps, the chief factors in emptying the blad-
der, \s, to some extent, inhibited. In some women recently
delivered the abdomen is scaphoid, so that a contraction of
the abdominal muscles actually decreases, instead of increasing,
intra-abdominal pressure. There is a third reason for the
retention of urine after labor : The tissues immediately behind
the symphysis pubis bear the brunt of the pressure of the child's
head as it descends the birth-canal ; and this pressure is exerted,
moreover, not directly forward, but to one side or the other, by
the oblique position of the head ; the tissues about the urethra
are left edematous after labor, from the contusion they have
suffered, and the urethra is dragged a little to one side, so
that in a twofold manner the urethral canal is partially
occluded, namely, by the edema of surrounding parts and
by the acquired tortuosity in its course. The urine itself does
not differ much from that of pregnancy. The aqueous portion is
increased ; the urea and solids are both relatively and actually
below the normal. Glycosuria is quite common. Blot claims
that the sugar in the urine is the result of the absorption of lac-
tose from the mammary glands, and that the larger the secre-
tion of milk, the greater would be the quantity of sugar in the
urine, and therefore he proposed that the quantity of sugar in
the urine be taken as a test for the suitability of a wet-nurse.
It has been claimed, by others, that the sugar has a hepatic
origin.

Fischel declares that peptonuria is a constant phenomenon
of the normal puerperium. ^

'"Arch. f. Gjm.,'* Bd. xxiv u. xxvi, S. 120 u. 400.

332 LABOR AND THE PUERPERIUM,

The sweat-glands after labor take on an unwonted activity.
The skin of a pregnant woman is often harsh and dry, and during
labor, unless the muscular effort is very great or the weather
very warm, the same condition of the skin persists. But in the
puerperal state the sweat-glands are unusually active ; the skin
is constantly moist, and during sleep the sweat, always increased,
may become very excessive. This action of the sweat-glands
plays an important part in the involution of the whole organism
after labor. It is one of the factors by which the hydremia of
pregnancy is corrected, and by the dissipation of heat that ac-
companies the rapid evaporation of ^vater all over the body the
temperature in the puerperal state is retained at a normal level,
in spite of many provocations to fever.

The lungs after labor take on a slightly different action.
Their capacity is increased, for the pressure from below is re-
moved and the play of the diaphragm becomes much freer.
Each inspiration drawing in more air than common, the number
of respirations in the minute becomes lessened ; the breathing
is deeper, fuller, quieter, and slower than it has been during preg-
nancy, and if the expired air were carefully examined, it would, in
all probability, be found to contain an excess of water and of
effete products, the result of tissue-destruction. As a result of
the great excretion of water from the kidneys, the skin, and, to a
lesser extent, the lungs, the thirst of the lying-in woman is in-
creased ; the appetite, on the other hand, is much diminished.
One can understand the last statement if he recalls the fact that
more than a pound of meat in the involuting uterus is absorbed
into the system during the puerperium, and if he remembers that
the woman is lying in bed absolutely quiet and expending no
force whatever in muscular action. There is still another factor
to account for the disinclination toward food. During pregnancy
there is no one tissue, except that contained within the develop-
ing uterus, which increases with so much rapidity as does the
subcutaneous fat. It seems as if there were provided by nature
a store of material which shall take the place of food in supply-
ing heat and force during a period when woman in her natural,
primitive state could not be supposed to provide for herself
This deposition of subcutaneous fat during pregnancy and its
subsequent absorption during the lying-in period account for
the remarkable changes in weight which may be noted in a
woman during pregnancy and after labor. This is a matter
'^ some practical importance, which does not usually obtain the

it deserves. It has been studied systematically by

ers, by Gassner many years ago and lately by

ding to Gassner, the gain in weight during

THE PUERPERAL STATE, 333

pregnancy and the loss afterward are about one-thirteenth of the
body-weight. This, I am incHned to think, from some investi-
gations of my own, is an underestimate, and Baumann's obser-
vations bear me out ; he found that the loss of body-weight was
about one-tenth after labor, the greater part of it, of course,
occurring in the first week, when a woman of average weight
will lose some nine or ten pounds.

All the remarkable changes observed in the lying-in woman
occasion no manifestation of disease, not even fever. This
assertion some years ago would have been most heterodox,
and would, indeed, have been incorrect, for fever was so
common in the puerperal state that it was regarded as physio-
logical ; it occurred usually within the first few days after labor
and as, at this time, there were marked manifestations of con-
gestion in the breasts, due to the inception of lactation, it was
called milk fever. In reality it was the fever of infection. If,
however, the temperature in the puerperal state is studied closely,
it must be confessed that there is some little irregularity, but that
irregularity is measured, in the normal case, by tenths of degrees.
Directly after labor, for instance, the body-heat is always a little
raised.

Although there is distinctly no such thing as milk fever,
the temperature is slightly affected when the breasts suddenly
assume their immense activity ; but the rise is rarely more than
a few tenths of a degree.

So many causes, however, transitory in their effect, can
produce slight disturbances in the temperature of the lying-in
woman, who is peculiarly sensitive to external influences, that
the rigid boundary which divides fever from a normal tempera-
ture at other times must be a trifle relaxed. Thus, it is agreed
among obstetricians not to regard as fever a transient rise of
temperature, lasting only a few hours, which does not go abov^
100.5°. This is the so-called physiological limit to the rise of
temperature in the puerperal state.

The Mammary Changes in the Puerpera. — Heretofore the
involution of important organs and systems in the puerperal
state has claimed attention. The mammary action after delivery
is a process of nwlution. The mammary glands, as their name
denotes, are glandular organs, only reaching their full develop-
ment, as a rule, in the female ; situated, usually, toward the lateral
aspect of the pectoral region ; occupying the space bounded
above by the third and below by the sixth rib, to the inner side
by the edge of the sternum, to the outer side by the axillary
line. They are derived from the epiblastic layer of the blasto-
dermic membrane, and belong essentially to the skin, as do the

334

LABOR A.VD THE PUERPEHIUM.

sweat and sebaceous glands. They are closely akin to the
latter, occurring in rare instances on indifferent parts of the
body, as the axilla, the abdomen, or even the thighs, where a
sebaceous gland has undergone a specialized development. In
the female they are hemispherical in shape ; they are held in
their normal position upon the pectoral muscles by the super-
ficial fascia, which splits into two layers one running above,
the other below tin. breast I- \temally a little below the middle

XiJ^J'

Fig. 197, — CE Cubo dal epithel at ceIIs F fal globules stained blnck with
DSItiic acid, uid seen both n tbe ctlls a d n the Central cav ty oi the Bcini ; Ci \
con nective- tissue fnune « th blood vessels Magn lied &oo(i uueten (C HeUimaniij .

Fig. tgS.—MiunmBry ({land or dog. showing the rornuttion of the KCRtion:
A. Mrdium condilion of growth of tin- cpilhelial cells ; B, a l.'ler cnndiEioa (sfter
Heidenhnln),

of the organ, is a protuberance, — the nipple : around this is an
area of pigmented skin, — the areola ; in this space are a number of
large sebaceous glands, — the glands of Montgomery. Internally
the breast is divided into excretorj' ducts, lobes, and lobules;
between the lobes and lobules are connective tissue and fat.
The lobules arc ultimately divided into little vesicles ; these
empty into a small excretory duct ; the small excretory ducts
a eontufuous lobules unite to form a single large, lactiferous

THE PUERPERAL STATE.

335

canal ; of these there are some fifteen or twenty, each conveying
the secretion from a separate lobe to the nipple; just before
emerging upon the surface of the nipple each duct is dilated to
form a small ampulla or reservoir for the milk ; as it passes
through the skin of the nipple, however, it is again con-
tracted. The epithelium of the gland is continuous with that
of the integument ; in the superficial portions of the lactiferous
ducts it is squamous ; in the deeper portions of the gland,
columnar. The function of the gland is the secretion of milk.
Colostrum. — During the latter part of pregnancy a thin,
opalescent fluid may be squeezed out of the breast ; directly

Fig 200 -Co]

stmm fliKl ordinnry

milk glob >lc9 <ir!.t

lay after lal

pnmpara ngel nine

«Q (an« Has .11)

after labor this fluid is somewhat increased in quantih ind bt
comes a little whiter and more opaqui.

At the end of about forty-ei{,ht hours i dtcidcd clnnge
takes place in tlie breasts ; they suddenly enlarge the skm over
them becomes tense; the cutaneous vems arc enf,orj,ed with
blood, and show swollen and distinct beneath the skin ; the
nipple projects ; to the feel the breasts are hard and lumpy ; to
the woman they are painful and tender on pressure. If the
clifld be now applied to the nipple, there runs out, almost with-

336 LABOR AND THE PUERPERIUM.

out suction, a quantity of human milk — a fluid different from
the colostrum just described. It is white, opaque, of a specific
gravity about 1035, is said to have a sweet, agreeable taste, and
is without odor.

The quantity of milk secreted in the twenty-four hours is dif-
ficult to determine. It might seem easy enough to draw the
milk from the breast at stated inter\'als with a breast-pump
and to measure it, but it is difficult to get a breast-pump as
mechanically effective as a child's mouth, and, moreover, the
secretion of milk depends, to sonic extent, upon the maternal
emotion ; the breast might almost be described as an erectile
organ ; certainly, the sight of the child arouses a maternal
instinct which scuds an additional blood-supply to the mammary
gland and undoubtedly increases the supply of milk. It has
been estimated that at first the quantity of milk is about 300 to
400 grams (10 to 135^ fl. oz.) ; by the seventh day it is 400 to
500 grams ( 1410 17 fl. oz.) ; after the second week, 1500 to 2000
grams — i yi to 2 liters (3 to 4 pints).

In a microscopic section of a mammary gland, procured
during lactation, there maybe seen large epithelial cells in the
process of proliferation. Toward their Inner periphery may be
seen globules of fat. One of two things must happen to account
for the production of the milk : either the whole cell, which
has begun to show signs of fatty degeneration, or rather fatty
metamorpho.sis, is cast off, then bursts and discharges its con-
tained fat, as well as other cell-contents, into the liquid medium
which has exuded from the blood, or else each cell, having accu-
mulated its store of fat, discharges it in little globules, along
with the casein, which must also be derived from the cell-
contents. Which of these two explanations is correct is a
matter still in di.spute. It is probable that the cells are multi-
plied, cast off, and rapidly replaced, — an action which occurs in
the production of sebaceous matter. This action of the mam-
mary gland is also in accord with the undisputed belief in the
close relationship between the breast and a sebaceous gland.
Biologists claim that one is but a great development of the
other ; that at birth the mammary gland in both sexes is very
iilje a sebaceous gland in every way, lunl that, in rare cases, as
alrc.idy sUti;d, a uiaoiUKtry i^Kind may be developed in all sorts
of odd places on tlic skin, and that the usual number in the
human race may be multipUed four or five times,

~ ~' - - - fium. — Occasionally it is impor-

> decide by an appeal to his own

in's statement, whether or not

To give a case in point, a

lelphia, a dead infant was

THE PUERPERAL STATE.

337

found under a hay-rick, A servant girl in the farmer's family
had attracted attention for some time before by her increased
size ; she had disappeared one morning for a few hours, and had
returned considerably altered in appearance, but able to go about
her work in a perfectly natural manner. Suspicion, of course,
pointed to her, and an examination confirmed it. The diagnosis,
in such a case, is not difficult. The lai^e uterus, reaching to
the umbilicus ; the bloody discharge, showing, under the micro-
scope, decidual cells ; the secretion in the breasts ; the charac-
teristic fragments of decidua that may be scraped out of the
uterine cavity with a curet ; the rents in the cervix, the vaginal
mucous membrane, and the perineum ; the relaxed abdominal
walls, and the stri:e upon them, — all unite to make the diagnosis
easy to establish and ab.solutely sure.

Management of the Puerperium. — The prevention of in-
fection must be the chief care of both doctor and nurse in charge
of a puerpera (see The Preventive Treatment of Puerperal Sepsis).
Having secured, so far as possible, a perfect cleanliness of physi-
cian, patient, all her surroundings and attendants, and of the air
of the room in which the woman lies, one has performed by far
tile most important part of his duty in the management of the
puerperal state, and has averted the commonest and most fatal
accident of this period — septic infection. Being secure of this
most desirable result, the physician may turn his attention to
some lesser matters, of no little importance, however, to the
comfort and even safety of the patient.

Visits. — It is wise to wait in the house for an hour after the
woman's delivery, to see that there is no hemorrhage. She
should be visited again in about twelve hours ; then once a day
for the first two weeks, every other day during the third week,
and once or twice in the fourth week. For the first week at
least the following items should be investigated routinely at each
visit; The pulse ; the temperature ; the odor, quantitj-, and char-
acter of the lochia ; the condition of the bladder and size of the
womb, learned by abdominal palpation : the condition of the
breasts and nipples ; tiie occurrence of after-pains ; the evacua-
tion of the bladder and bowels, and last, but by no means least,
the condition of the infant. Many physicians fall into the habit
of neglecting the baby altogether. There could be no worse
policy, not to speak of higher considerations. The mother
resents an indifference to her infant's condition, and a failure to
makn a routine investigation at each visit of the child's feeding.
■'"", and gain in development : of its umbilicus, its bowel
Idcr evacuations, and digestion, often results in a failure
some abnormality until it is too late. Many a sudden

338 LABOR AND THE PUERPERIUM,

and inexplicable death in the new-bom could have been avoided
by greater watchfulness and care.

Rest and Quiet. — The woman recently delivered is the picture
of perfect restfulness and repose. There is reason enough for
this mental and physical quiet after delivery. The relief from great
suffering and tremendous muscular effort would naturally induce
a feeling of lassitude, and fortunately it is preeminently the
case after labor, for this condition of perfect repose is most
favorable for the occurrence of the complicated phenomena of
the puerperium without detriment to the woman's health. It
seems almost superfluous to insist upon the advisability of ac-
cepting this hint from nature in the management of the puerperal
state,-^-of preventing any mental or physical disturbance, mus-
cular effort, a glaring light, loud conversation, and, more than all,
the entrance into the lying-in room of a single person whose
presence is not necessary, — and yet this is a matter that in many
cases requires the physician's express attention. Among more
ignorant people particularly, and especially if there has been some
unusual complication or accident in the labor, the patient, upon
the second visit, may be found restless, with a rapid pulse, an
anxious expression, and an elevated temperature, and on in-
quiry it is learned that a constant stream of her female neigh-
bors has been pouring into her room with minute inquiries into
the particulars of the case, and often with gloomy forebodings
as to the result, based upon their recollection of just such a case
which ended fatally. This is not a fanciful picture, but a per-
sonal experience, many times repeated in my earlier practice as
a district physician. I have sometimes thought that our lower
classes have not much improved in this particular upon the
peasantr>^ or bourgeoisie of France in the seventeenth century,
who were accustomed to baptize the infant on the third or fourth
day, on which occasion a collation was served in the lying-in
room, to which all the friends of the family were invited, who
were all expected to drink the mother's health with much
hilarity and many congratulations, — a ceremony which lasted
through a whole afternoon. Mauriceau speaks of this as a
** very ill custom." We must all agree with him, and should
be inclined to go to the opposite extreme in enforcing rest and
seclusion during the whole lying-in period.

The physician must give specific directions in regard to the
following matters, under the head of Rest and Quiet :

I. The position that the patient must occupy in bed, and
how long she must retain it. The length of time she must
remain in bed. The earliest date she may stand upon her feet,
and the time when she may go down-stairs.

THE PUERPERAL STATE. 339

2. The degree of quiet and decorum to be observed in the
room ; and —

3. The admission of visitors.

The rules in regard to these matters, expressed, as rules,
dogmatically, might run as follows :

1. The patient shall lie flat on her back and shall not be
allowed another posture for at least a week. For the first six
hours after labor the head shall not be supported by a pillow,
but shall be on a level with the body, in order to avoid a
disposition to cerebral anemia and syncope, from the greatly
decreased abdominal pressure.

The woman must lie in bed until the involution of the uterus
is so far complete that the fundus uteri has sunk to the level of
the symphysis pubis or below it. It is a safe rule to insist upon
strict confinement to bed for fourteen days. Then the patient
may be allowed to shift herself from the bed onto a lounge
rolled alongside of it, passing the day upon the lounge and sit-
ting up as long at a time as she can without fatigue. At the
end of three weeks she begins to walk about the room, and at
the end of four goes down-stairs for the first time.

2. The woman's rest must be mental as well as physical ;
therefore, no loud noises should oflend her ear, no glaring light
should irritate the eye, and no extended conversation should be
allowed in the lying-in room ; at any rate, for the first few
days.

3. No visitor should be allowed in the lying-in room except
the patient's mother and her husband, and it is sometimes neces-
sary to restrict the visits as to frequency and length.

These rules in regard to quiet after labor will suit the aver-
age case among the upper classes. They must, however, be
modified on occasion. The length of time, for instance, required
for the involution of the uterus varies greatly in different classes
of society. An Indian tribe on the march does not halt because
a woman falls in labor ; she retires to the bushes, gives birth to
her infant, cuts the cord, dresses the child, and plunges into
the nearest stream to cleanse herself ; remounting her pony, she
soon rejoins her tribe with the new-born infant slung on her
back. The involution of her uterus goes on rapidly, in spite of
this heroic treatment. In the Frauenklinik in Munich, in which
the author once served as volunteer interne, and where the pa-
tients are mainly strong Bavarian peasant girls, the fundus of the
uterus was usually beneath the symphysis pubis on the sixth day.
On that day the patient left her bed ; the following morning she
walked out of the hospital with her infant in her arms. In the
more artificial life of a member of what is called the upper

340 LABOR AND THE FUERPERIUM.

classes, especially in this country, much of the primitive woman's
physical vigor is surrendered for increased mental culture. In
these women labor is usually difficult and painful, if not danger-
ous ; the puerperal state is often a far more complicated period
than it should be, and the return of the uterus to its natural
size may take much longer than the average time.

No patient should be allowed to leave her room before a
careful vaginal examination has been made, to ascertain the
position of the uterus. This one examination, however, is not
sufficient. Even after involution is almost completed, when the
woman resumes, to a certain extent, her normal activity, a uterine
displacement is not unlikely to occur. Overexertion or exposure
will almost certainly bring on a renewal of the bloody lochia;
the involution of the uterus may be arrested before its perfect
completion ; even septic inflammation may attack the uterus and
its appendages as late as the fourth week. I make It an invari-
able rule of practice, therefore, to examine every child-bearing
woman under my charge six weeks after her delivery, digitally and
with the speculum, noting the position of the uterus, its involu-
tion, possible injuries to the cervix or pelvic floor, erosions of
the cervix, and the character of the uterine dischai^e. I have
many times found abnormalities at this period, which were not
noticeable or were not present before the woman left her room.
The question whether the routine administration of ergot would
insure perfect involution or hasten its completion has, of course,
occurred to many minds, and has found its answer in practical
experimentation. Large numbers of women in several lying-in
hospitals in Europe, under the independent observation o^ com-
petent observers, have been placed on a routine treatment of
ergot three times a da)', and the progress of these cases has
been carefully compared with that of an equal number of women
left to nature. The result of these observations has not been
favorable to ergot as a sure means of shortening the duration
■ of the puoqjeral state: riolliiiig w;i.s L;:iii]o<l in p.iint of time,
■^ while disadvantages were found to attach to thi,'; plan of treat-
ment that miglit have been foreseen. The stomach rebels
vunst a prolonged use of the drug in considerable quantities.
WWc contfactitig the uterus, it has an astringent action also
^ tffe blT**^ and so diminishes milk secretion, and, passing
~ " t, oWtcmal blood into the milk and into the infant's
t.^g«ltt *ll unfavorable influence upon both mother

J ^^t— This is a mailer of no small importance, about
j^>e A oonsWcrabilc difierenee of opinion. On the one
* iMttaI'dK woman after Inlinr is weak from loss of

THE PUERPERAL STATE. 34 1

blood and from fatigue ; that she must, therefore, receive the
most nourishing food in the largest possible quantities. And,
moreover, that the demand which will soon be made upon her
economy for the nourishment of the child is an additional reason
for the administration of a generous diet from the first. But a
close observation of nature should lead, I think, to the opposite
view. A large part of the involuting uterus is absorbed into
the system ; some two pounds of meat are thus, as it were,
devoured, the greater part of it in the first few days of the
puerperium. A large quantity of fat is stored up in the body
during pregnancy with the express purpose, it would seem, of
providing a means of supporting the woman during the early
part of the puerperal state. Thus nature provides a sustenance
which in quantity certainly appears suflRcient for at least the
first few days after confinement, and in form and manner of
ingestion, so to speak, is best calculated to support the woman's
strength, with none of the expenditure of force involved in
mastication and digestion. Moreover, it must be remembered
that almost all the vital functions are performed in a sluggish
manner for the first few days after labor. The pulse is less
rapid, the respiration slower, the bowels are inactive, and there
should be no voluntary muscular effort. All this seems to
argue for the wisdom of a system which allows, for the first
few days, nourishment small in quantity, of a form easily ingested,
and of a quality readily digested. After the third day, however,
a new element must be taken into account. At that time there
begins the milk secretion, which undoubtedly entails a great
drain on the whole system to provide the large quantity of fat
and nitrogenous material which are excreted when the breasts have
assumed their full activity. To meet this additional demand
upon the resources of the body the simple diet of the first few
days should be materially, though gradually, increased ; for the
first onset of the physiological mammary action is usually so
violent as to stop just short of a pathological condition, — inflam-
mation,— and suddenly to exhibit large quantities of nutritious
food at this time would very likely cause a transgression across
the boundary-line between health and disease. This, however,
is mere theoretical reasoning, and if applied in practice it fails to
give the best results, the system dependent upon it should be
ruthlessly discarded, no matter how reasonable it may appear.
But a practical test has given the result that might be expected.
No one who has compared the two methods — one, of giving a
forced diet from the first ; the other, of giving a very light diet,
chiefly of milk, for the first two days, and afterward gradually
increasing it until, on the sixth or seventh day, the patient is

342 LABOR AND THE PUERPERIUM.

taking the food that would be suitable to any healthy person
confined in bed without physical exercise— can fail to notice that
the latter plan secures a far greater immunity from inflanimator>'
disturbances about the genitalia and the breasts, and from irreg-
ularity in the milk secretion and the action of the stomach and
bowels.

Urination. — The tendency to retention of urine that is so
often met with, especially among women city bred and in easy
circumstances, has already been noticed. This is an abnor-
mality in the puerperal state of civilized woman that is, per-
haps, as annoying as any one feature of a normal case. Its
causes have already been described. Its detection would seem
perfectly easy, and yet it is just as easy to overlook it without
the careful attention which should be, but is not always, directed
toward this point It is a common experience for a consultant
to be asked to see a woman some days after labor, because the
attending physician thinks that alongside the uterus there is a
large and peculiar abdominal tumor, and the patient suffers great
pain. What is taken for the uterus is an immensely distended
bladder, reaching half-way to the umbilicus ; the peculiar ab-
dominal tumor is the uterus itself pushed far upward and to one
side, almost always the right. Catheterization removes immedi-
ately both tumor and pain. The mistake on this point often
arises from the trust that the physician puts in the woman's
statement that she has urinated regularly. One should never
trust any one's assertion as to action of the bladder, but should
always examine for himself, by abdominal palpation, to see
whether it be full or not. A nurse sometimes falsely asserts
that her patient has urinated, because she \s ashamed to confess
hor inability to pass a catheter. If the urine must be drawn, the
oathclor is used by a trained nurse, should there be one. Among
the palionts. lunvcvcr, which fall to the lot of most physicians
when tluy boi^in to practice, a trained nurse is a luxury abso-
hUolv uni^htainai)lc, and the physician himself must attend to
Ov \\Uhoiori/alion ; even if a skilful nurse is in attendance, the
^^^>\^^uu\ ts not infrequently appealed to, as the nurse can not
H<^>v>^\\^v thx^ uivtiira. or is unable to insert the catheter. It is
\XVs5s ^tu'u JxMw under all circumstances, to know how to use a
VnhOv.'^v^ sVAxI tx> havo a definite opinion as to the kind of instru-
VSVt^^^ ^^-A^ xV^s^v.Ui Iv cniplovcd. A soft-rubber catheter is to be
^v^S^*;ssl sx\ c^/.sx^ \\ is incapable of doing any harm, does not
'ftV?<AV ^^s' ^Mv!;':ua. and is easily cleansed and kept clean.

A'ftv^ W^'\^ u>s\t .1: N^A^iiIvi Ik' rinsed out and should be kept per-
Yi^^iS»i*»V;\ ^'U!^K k-kVNt ,a a \ : J<.XK) solution of sublimate. Before

NmAj;; i>Vv^ '\ !Hi,i>5 *:v.' vv,iv,K\l in a basin of sterile water, and its

THE PUERPERAL STATE. 343

tip should then be oiled. The hands of the individual who
inserts it must be aseptic. As to its manner of introduction : It
is necessary to expose the urethra to view, to wipe off its mouth,
as well as the surrounding mucous membrane, with a piece of
absorbent cotton moistened with a sublimate solution, i : 2000,
and then to introduce the catheter, being sure that it is going
into the right place and that it is not carrying with it into the
bladder some of the decomposing vaginal discharge, which would
be likely to set up a very troublesome or a very dangerous
cystitis. The old practice of locating the urethra by the sense
of feel, using the finger of the left hand and then introducing
the catheter held in the fingers of the right hand, under a sheet,
is to be unreservedly condemned.

In the Directions to Nurses, apjjended to this chapter,
occurs the passage, ** Twelve hours after labor the woman
shall be catheterized, and after that three times a day if
necessary.** Twelve hours may seem a rather long period to
allow urine to collect after labor ; but the bladder is capable of
great distention at this time ; almost all the natural processes
are sluggish ; the kidneys directly after labor are not very active,
perhaps because the sweat-glands at this time take on unwonted
activity, and if the catheter is used too soon, the patient is very
likely committed to its use throughout the greater part of the
lying-in period, whereas if the woman can be induced to urinate
naturally at first, there will be no difficulty afterward. At the
same time it would be unwise to allow an overdistention of the
bladder ; twelve hours, therefore, is a good compromise time for
the first use of the catheter. After that three times a day is usually
quite sufficient ; it should not be used less frequently, and if the
patient's feelings demand it, the bladder must be emptied more
frequently. By this plan I find it necessary to use the catheter
in about thirty per cent, of primiparae. It is possible, by a longer
delay, to reduce this proportion materially. In the Baudelocque
Clinic they wait twenty-four hours or longer and have used the
catheter in 6666 cases only twenty times. * Before resorting to
catheterization every effort should be made to induce the
woman to urinate naturally. Sometimes this is accomplished by
putting hot water in the bed-pan, by the use of a turpentine
stupe over the bladder, and by the sound of running water.

The Bowels. — On account of the small amount of food in-
gested during the early part of the pucrperium, the flaccidity of
the abdominal walls, the torpor of the intestinal muscles from
long pressure, and the general muscular inactivity, there is a re-
markable sluggishness of the bowels, and an exaggeration of the

1 Recht, " TWse de Paris," 1894.

344 LABOR AND THE PUERPERIUM.

constipated habit almost invariably acquired in pregnancy. This
is no great disadvantage at first, as the food is principally liquid
and small in quantity, so that there is very little detritus to be
thrown off by the intestines. It is not advisable, however, to
allow the feces to accumulate too long. If the woman eats in a
day perhaps a third of what an ordinary person would devour,
by the third day there would be a considerable collection in the
lower bowel ; at this time, too, the diet is a little increased, and
the sudden onset of milk secretion on the third day always seems,
at least, to threaten an inflammation of the breasts, which might
be averted by a derivative and depletive course. For all these
reasons, therefore, it is customary to administer as a routine
treatment a laxative on the evening of the third day. What
this laxative is may be decided by the patient's inclination or
prejudice. Castor oil is undoubtedly the most suitable agent ;
most efficient, least apt to be harmful. But there are many
persons who will not take it. A good way to administer it in
cases where it may be given is to put it in warm milk ; there is
nothing else perhaps which disguises the taste so well. Or it
may be given in the more common way along with the froth of
malt Hquors, especially porter, or in soda-water. My routine
prescription is a half-bottle of citrate of magnesia on the evening
of the second day, the rest of the bottle the following morning
before breakfast, and, if the bowels are not moved two hours
later, an enema. If the patient is plethoric or the mammary
glands are very swollen and tender, a more active saline purge
would be preferable.

The Mammary Glands. — ^The mammar}' glands require judi-
cious management in the puerperal state. There are many
pathological conditions, functional and structural, which often
arise and which demand care and skill in their treatment. These,
however, will be considered in their appropriate place. There are
other conditions, not a little troublesome to deal with, of such fre-
quent occurrence that they must be considered in discussing the
management of a normal case. In almost every instance the
establishment of lactation is accompanied by some local disturb-
ance. The increased blood-supply to the breast, the proliferation
of cells, and the transudation of a serous exudate are phenomena
usually ciiaracteristic of inflammation ; and the enlarged breast,
the engorged veins under the skin, the hard, tense feel of the
gland- tissue, and the ij^reat tenderness, all seem to point to an
inflammatory attack instead of a natural physiological process.
This state of the breasts usually demands some treatment, not
only to ameliorate the discomfort that is almost always experi-
enced, but to prevent the transition of a natural process so

THE PUERPERAL STATE, 345

closely bordering on the pathological to a condition of actual
disease. If the engorgement of the breasts is very marked and
the accompanying symptoms of heat, pain, and fullness are
very pronounced, the administration of a saline purge usually
proves a sufficient derivative, and relieves some part of the
mammary congestion. Care must be taken, in addition, to secure
the evacuation of the secretion collecting within the gland, and for
this purpose nothing is so good as the infant's mouth, which should
be applied to the nipple regularly every two hours. If these
simple devices are not sufficient ; if the child is not living or must
be weaned, more active measures should be employed. If the
secretion is excessive, a breast-pump must be used, and the
nurse, in addition, should rub and massage the breast with oiled
finger-tips in a direction toward the nipple, thus making the skin
more supple and emptying the breast at the same time. Often, in
addition to this, it is well to apply some lotion of an astringent and
soothing nature. I have found nothing so good for this purpose
as lead-water and laudanum. Cloths should be soaked in it and
applied over the whole breast. If the infant is nursing, care must
be taken, of course, to remove any poisonous substance that might
be on the nipple. The constant dragging upon the nipple when
the child is nursing, the pinching and squeezing it receives from
the infant's gums, and its continual moisture from milk and the
secretions of the infant's mouth, all tend to bring about an un-
healthy condition of the skin upon and around the nipples. It
becomes at first irritated and inflamed, then excoriated, chapped,
and fissured, and, consequently, exceedingly sensitive and pain-
ful, so that the application of the child is regarded with dread.
Nor is this the only disadvantage ; in the little cracks and
fissures the milk collects and decomposes ; the patient or nurse
may, in careless handling of the breasts, deposit, in these raw
places, some of the many forms of septic micro-organisms,
and the consequence is very likely to be septic infection of the
connective tissue of the breast and the formation of a mammary
abscess — of all the minor complications of the puerperal state the
one to be most dreaded. The preventive treatment of this com-
plication plays an important part in any scheme of managing the
puerperal state. The main thing, obviously, to be secured is
cleanliness and a healthy condition of the skin. This is obtained
by carefully washing the nipples after every nursing with some
absorbent cotton, warm water, and Castile soap ; by cautioning
nurse and patient against handling the breasts witli fingers not
aseptic, and by smearing the skin of the nipples and that of
surrounding parts with sweet-oil after every washing, applied by
a piece of clean linen or a pledget of fresh absorbent cotton.

346 LABOR AND THE PUERPERIUM.

There is another point in the management of the breasts, which, if
it does not aid in preventing so serious a disturbance as mam-
mary abscess, does increase the patient's comfort by reheving the
feeling of distention and weight which is experienced during the
first few days of lactation. This is the adjustment of a suitable
mammary binder. I find the best one for this purpose to be the
Murphy binder (Fig. 201).

The Child. — While devoting careful attention to the man-
agement of a woman after confinement, the physician must not
forget that he has another patient on his hands, of almost equal
importance, — the infant. Fortunately, the management of a
healthy infant is not a very heavy charge on one's ingenuity.
If a few common-sense rules are observed, nature will do the
rest. The management of the new-bom child consists simply
in seeing that food is administered at proper and regular inter-

The Mur|>hy breast binder.

vals, that attention is paid to bodily cleanliness, and that ample
opportunity is afforded for an almost unlimited amount of sleep ;
with ordinary precautions, of course, in regard to warmth, for
the infant has just emerged from a constant temperature of 99°
and can not offer much resistance to cold. The proper interval
between the nursing should be two hours during the day, four
to five hours in the night. If the child is taught regular habits
in this respect, the burden of its care-takers is immensely
lightened. The infant arouses itself and is ready for nursing
[It lln.- |.i.i|nT lfL-(JL!ij;-tinK-. .uiil 111 lilt- mi<r\,ils slvi[i> pc.ice-
fiiily. Rut;ularily in nursing i.s of inijfnrt.incc, turllicr, fnini its
favorable influcnci:_Uf)Din the constitution of the milk. Too
concentrated milk, which is difficult
; results in a watery milk.

THE PUERPERAL STATE, 347

which is not nutritious. If, on the contrary, the infant is allowed
to be irregular in the hours for feeding, bathing, and sleeping,
it grows fretful, wakeful, and capricious in its appetite. One
word of caution is necessary about the infant's bath. The tem-
perature of the water should be about 90*^ ; certainly not much
higher, nor, on the other hand, too low. Nurses are often
extraordinarily insensitive to hot water. The temperature • of
the bath, therefore, should not be tested by their hands, but by
a bath -thermometer. The bath should be given about midday,
in the warmest part of the room, preferably in front of an open
fire.

There are many apparently small, but really important, details
in the preparation for and management of labor and the puer-
perium, which might easily be forgotten. I find it convenient,
therefore, to give to my patients and nurses the appended list of
instructions.

DIRECTIONS FOR THE MOTHER.

Send a specimen of urine (mixed night and morning), about four
ounces, every two weeks until the last month, then every week.
Report at once scanty urination, severe headache, swelling of the feet
or face.

Have ready for the labor: towels, ether (one-half pound), brandy
(two ounces), vinegar (four ounces) ; four ounces tincture of green
soap ; a bottle of antiseptic tablets (corrosive sublimate); a large,
coarse, new sponge ; a skein of bobbin ; a fountain syringe ; bed-pan ;
new, soft-rubber catheter ; a small package of absorbent cotton ; a
one-ounce bottle of carbolized vaselin ; two yards unbleached muslin
(for binder); a one-pound package of salicylated cotton ; fiw^ yards
of carbolized gauze ; eight yards of nursery cloth.

The last is to be boiled for half an hour in clothes-boiler, dried
thoroughly, pinned up in a clean sheet, and put away out of the dust.
A mackintosh or rubber cloth is necessary to protect the mattress ;
two yards of rubber cloth, one yard wide, is sufficient. Prescription
No. I ^ is to be procured about four weeks before expected confinement.
It is to be applied to the nipples, night and morning, with absorbent
cotton. Prescription No. 2 2 is to be obtained about a week before-
liand and kept in readiness.

Baby-clothes.

Four to six dozen diapers.

Four to six pairs knit (woolen) socks.

Three to four shirts (woolen).

^ &• Glycerol of tannin.

Aqua, ^' .5J ..

»R. Ext eigot fld., fgj.

348 LABOR AND THE PUERPERIUM.

Four flannel night..kira. | ^„ ^^^^ ,^ ^ ^^^^ ^^^ ^^^ ,„^„^

" ■; tT'i' „•• { of bands.
Four to SIX white day-skirts. J
Six to ten slips.

Material for four or five flannel bands (45- to so-cent flannel).
Soft pillow (good size, 14 x 18 inches).

" " covers.
Knit wrapping blankets.
Sacques, wrappers, bibs, caps, blankets, veils, etc.

Baby's Basket.
Large and small safety-pins.
Talcum powder (box and puff).
Fine, soft sponge.
Soft brush (for hair).
Castile soap.
Cold cream.

Alcohol for rubbing child.
Blunt scissors for nails, etc.
Old linen for cleaning mouth.
Soft towels for bath.
Bath-blanket.
Wooden forms for drying socks.

DIRECTIONS FOR THE NURSE.

Give rectal enema as soon as pains begin (pint of soapsuds, dram
of turpentine). Have the patient wash the external genitals thor-
oughly with soap and warm water. As soon as labor begins, fill three
pitchers with water that has been boiling for half an hour ; tie clean
towels over their tops. This water is to be used for all purposes about
the patient and for making the antiseptic solutions.

No vaginal injection to be given unless ordered.

Take the temperature three times a day, — morning, noon, and
evening.

Place pad of nursery cloth under patient ; change it when soiled.
Ot:c!usive handa^je to he made up of salicylaied cotton and carbolized
gauie, with dean hands, and to be changed, for the first five days,
every four hours.

The external genitals to be washed off four or five times a day
a corrosive sublimate so!utioi>, 1 : 4000, made up with lioiied
water. Use absorbent cotton for this purpose.

If, at the end of twelve hours, the Maddet an ti«t be cmpiied
naturally, use a catheter. Afterwar<|,i irwagHWy, calbcicriEc patient
three times a day. " ^^^""^^ '

The patient is to lie (
side of the bed to the fl
rubbed with alcohol axA 1

THE PUERPERAL STATE. 349

Tbe nurse's hands are to be washed with a nail-bmsb,
soap, and water, and rinsed In a i : 3000 sublimate solution

before catheterizing the patient or cleansing the genitals or breasts.
Diet. — First 48 hours. — Milk '("J^ to 2 pints a day), gruel,
soup, one cup of tea a day, toast and
butter.
Stcorui 48 hours. — Milk toast, poached eggs, porridge,
soup, cornstarch, tapioca, wine-jelly,
small raw or stewed oysters, one cup
of coffee or tea a day.
Third 48 hours. — Soup, white meat of fowl, mashed pota-
toes, beets, in addition to above.
After sixth day, return cautiously to ordinary diet, — that
is, three meals a day, meat at one of them, of an easily
digested character, — white meat of fowl, tenderloin of
beef, etc., — and a glass of milk at least three times a
day, between meals and before going to sleep at night ;
also a glass in the middle of the night.
Child. — After being well rubbed with sweet-oil, the child is to be
washed on the nurse's lap. The bath-tub may be used
by the end of the first week. Water not over 100" F,
The cord is to be dressed with salicylated cotton. Ob-
serve carefully for bleeding. A good dusting -powder
for the navel is salicylic acid i part, starch 5 parts.
The child should lie bathed daily, about midday, in the
warmest part of the room. Use Castile soap and a soft
sponge ; avoid the eyes.
Diapers changed often enough. For chafe, use cold
cream and talcum powder.
Nursing. — The child is to be put to the breast every four hours
for the first two days. No other foodis to heaven it. After the second
day it should be nursed every two hours, from 7 a. m. to 9 p.m., and
twice during the night (i a. m. and 5 a.m.). After every nursing
the nipples are to be carefully dried and then smeared with a little
sweet-oil for the first week or two, applied with fresh pledgets of
■taorbentc

PART III.
THE MECHANISM OF LABOR.

The mechanism^ of labor is the manner in which a fetus and
its appendages traverse the birth-canal and are expelled. It
takes into account the complicated structure of the maternal
and fetal parts, considering their movements and the mechanisms
of their motions.

It is necessary to define, further, certain terms that will be used
constantly in the study of the mechanism of labor.

By presentation is meant that part of the fetal body which
presents itself to the examining finger in the center of the plane
of the superior strait.

The term position may be applied to the position of the
child in utcro, whether it is longitudinal, oblique, or transverse ;
or, in another sense, it is the varying relations which the present-
ing part of the fetus bears to the surrounding maternal structures
at the plane of the superior strait.

The presentation and position of the fetus are determined by
abdominal palpation, by auscultation, and by vaginal exami-
nation.

Abdominal Palpation. — For this kind of obstetrical exami-
nation the woman should be placed on her back, with the
abdomen exposed. The examiner, standing to one side of the
patient, by a series of stroking, patting, and rubbing motions
with his hands, determines the height of the fundus uteri, the
tension of the abdominal walls, the irritability of the uterus, the
quantity of liquor amnii, the size of the fetus, its position, and its
presentation. It has been claimed that in favorable cases the
placenta can be felt, and that its position can thus be diagnosti-
cated (Spencer). It is further asserted that if the greater bulk
of the uterus is anterior to the insertion of the tubes, the pla-
centa is anterior, and vice versa (Leopold).

^ From the Greek fujxdyr/y coiUrivance, machine (from root fivx^i * manner, a
way, a means).

350

ABDOMINAL PALPATION.

3SI

The Diagnosis <^ Fetal Position and Presentation by Abdotm-
nal Palpation. — The examiner stands alongside the patient,
facing her head ; the tips of the fingers of both hands, moving
together and at equal distances, are carried up the sides of the
abdomen by a series of tapping movements ; and upon one side
(for example, the left, in the L. O. A. position) is noticed a firm,

Fig. 303. — AlidoininBl palpatioii ; lindiDg the lower

broad, even sense of resistance, contrasting with the cystic, tumor-
like sensation of the other side, with the occasional encounter of
firm, irregular bodies, — the fetal extremities.

This firm, broad, even resistance is produced by the fetal
back, and, to confirm this fact, the extremities are felt for by
a rubbing motion, with one outstretched hand on the opposite

352 THE MECHANISM OF LABOR.

side. They are felt as cylindrical, irregular bodies, slipping away
from the hand, and changing their position from time to time.
Having located the back and the extremities, the portion of the
fetal ellipse presenting at the superior strait is next ascertained.
The examiner now faces the woman's feet, and, with the out-
Stretched hands, the fingers parallel with and the middle finger
over the center of Poupart's ligament, on cither side, the fingers
dip down beneath the ligament into the pelvic cavity. If the
head is presenting, it is felt as a hard, regular, round body,
the greater mass of the occiput, the sharp point of the chin,
and the groove between occiput and back being often distin-
guishable. At the same time, the density of the head, its com-
pressibility, its approximate size, and its relative size to the
pelvis may be learned.

Fig. 204. — Abdoroinal palpation; locating the fetal head.

By auscultation the fetal heart-sounds are located, and their
rate and intensity are noted. The uterine bruit and the funic
souffle arc often heard. The position on the abdomen at which
the fetal heart-sounds arc heard with greatest intensity is of
diagnostic value in confirming the find, by abdominal palpation,
as to position and presentation.

I!y vaginal examination the finger detects the varying por-
tions of the fetal body which may present at the superior strait,
as the cranium, the face, the shoulder, the buttocks, the knees,
feet, and, exceptionally, the elbow or hand.

The po.tition of the futus in iitfro \s longitudinal in 99^^ p?r
cent, of all ca.ses. Tlie cephalic extremity presents in about
95 .'-i P*^'' cent., 95 ])er cent, being vertc.-v presentations. In
about one-half of 1 ])er cent, of ca.ses the face presents ; the
brow ver>' rarely. In about 3 per cent, of all cases the breech

PRESENTA TIONS AND POSITIONS. 353

presents, and in about one-half of i per cent, the fetus occupies
a transverse position /;/ utero.

An explanation of the ST^at frequency of cephalic presentations

is found in a voluntary assumption of that position by the fetus,
because it affords it the greatest degree of comfort and the best
opportunity for growth and development, the largest room being
found in the fundus uteri for the lower extremities, which are
freely moved and exercised.

An explanation of the ST^at frequency of presentations of the
vertex is afforded by the mechanical arrangement of the connec-
tion between fetal head and body, diagram
matically represented by two bars attached
to each other, — that representing the head
joined to that representing the spinal col-
umn, not at its middle, but at a point
nearer one end of the bar (Fig. 205). An
equal force exerted upon both ends of
the lever represented by the child's head fig- 205.— Diagram

will result in the greater flexion of the '""sf^ii^s ^^e cause of

1 . I . .1 . .. r .1 "^^ frequency of vertex

longer bar, which is that portion of the presentations,
fetal skull in front of spinal column.

The positions of the various presentations are named by the
relationship which the most prominent anatomical feature of the
presenting part bears to the acetabula or the sacro-iliac junctions
of the maternal pelvis. They are, therefore, four in number.

Positions of Vertex Presentations. — I. L. O. A., left occipito-
anterior, the occiput looking to tiie left acetabulum. 2. R. O. A.,
right occipito-anterior. 3. R. (). P., right occipitoposterior,
the occiput looking to the right sacro-iliac joint. 4. L. O. P., left
occipitoposterior. Of all vertex presentations about seventy per
cent, are L. O. A., thirty per cent. R. O. P. The long axis of
the fetal skull very rarely lies in the left oblique diameter of the
maternal pelvis.

Explanation of the Frequency of L. O. A. and R. O. P. — The
position of the rectum shortens the left oblique diameter of the
pelvis ; therefore the long diameter of the head, seeking the
direction of least resistance, adjusts itself in the right oblique
diameter of the pelvis and the projection of the lumbar spinal
column, to which the fetus by choice adapts its anterior concave
surface, usually results in the back being turned forward and
tilted a little toward the right, because of the usual right lateral
version of the pregnant uterus. Thus, the left occipito-anterior
position of the vertex \% the commonest position in labor.
Should the child's back be directed to the right, the occiput is
turned posteriorly, because the chin would be pushed forward

354

THE MECHANISM OF LABOR,

by the sigmoid flexure and rectum, this being a stronger force in
the arrangement of the head than the child's incHnation to adapt
its concave abdominal surface to the convex surface of the lum-
bar spine.

THE FORCES INVOLVED IN THE MECHANISM OF LABOR.

There are certain forces operative in every labor irrespective
of fetal presentation and position. These are the forces of
expulsion contributed by the uterine muscle and the abdominal
muscles, and the forces of resistance contributed by the lower
uterine segment, the cervix, vagina, vulva, the pelvis, and the
fetal body.

Fig. 206. — Diagram showing the diminution of the upper uterine segment and the
expansion of the lower segment during each contraction.

The forces of expulsion are furnished by a great part of the
uterine muscle (the upper uterine segment) and by the muscular
action of the abdominal wall. That portion of the uterine canal
which must be dilated to allow the escape of the fetus is called the
loweruterinc segment. Its boundaries are : above, the firm attach-
ment of the peritoneum to the uterine wall, and, below, the
internal os. That portion of the uterine wall above the point at
which the dilatation of the uterine cavity begins is called the
upper uterine segment ; the boundary-line between these seg-
ments, often marked by a perceptible ridge, especially in ob-
structed labors, is called the eontreiciion ring, or the ring of Bandl.

FORCES INVOLVED IN MECHANISM OF LABOR.

355

The manner in which the uterine muscle exerts its force
upon the fetal body is by a diminution of the intra-uterine area.
The uterine muscle in contraction somewhat increases the longi-
tudinal diameter of the uterus, but decidedly diminishes the
transverse and anteroposterior diameters. The contraction of
the abdominal muscles likewise diminishes the area of intra-
abdominal space. The degree of force exerted by the combined
action of uterine and abdominal walls has been estimated at
from seventeen to fifty- five pounds. The forces of resistance
are furnished by that portion of the parturient tract which
must be dilated, — /". c, from the contraction ring to the vulva,
including the lower uterine segment, the cervix, the vagina, anu
the vulva. The dilatation of the cervix is effected, if the
membranes are preserved, by the displacement of the most
easily displaceable of the uterine contents, the liquor amnii, in

Fig. 207. — Diagram illustrating Fig. 208. — Diagram illustrating
the alteration in the shape of a cross- the alteration in the shape of a sagittal
section of a uterus during its contrac- section of the uterus during its contrac-
tions. The heavy line represents the tions. The heavy line represents the
non-contracted, the dotted line the con- non -contracted, the dotted line the con-
tracted, uterus (compare Fig. 208). tracted, uterus.

the direction of least resistance, — through the cervical canal.
A pouch of the membranes insinuated in the canal subjects the
surrounding ring of cervical muscle to water-pressure, equally
exerted in all directions, but felt by the cervix only in a lateral
or horizontal direction. If the membranes are ruptured and the
presenting part impinges directly on the cervix and lower uterine
segment, the former is subjected to a lateral pull from all sides
at once, as the presenting part pushes from above downward.
The presenting part, moreover, whatever it be, is somewhat con-
ical in form, and subjects the cervix to a lateral push as it is
wedged into the cervical canal (Fig. 209). The dilatation of the
lower uterine segment and of the cervix is not, however, simply
mechanical, the serous infiltration of the lymph-spaces and the

3 56 THE MECHANISM OF LABOR,

separation of the muscle-fibers lessening the power of resistance
gained by cohesion of muscle-bundles.

The dilatation of both the lower uterine segment and the cer-
vical canal is also assisted by the longitudinal muscle-fibers in
these regions drawing the cervix up over the presenting part.
Finally, the circular muscle of the cervix, subjected to the strain
of constant push and pull, becomes fatigued and, at length, para-
lyzed. Below the cervix dilatation is effected mainly by the
mechanical stretching of the walls of the birth-canal.

The bony walls of the pelvis, in a normal case, only offer enough
resistance to delay the progress of the presenting part suffi-
ciently to insure a gradual dilatation of the soft, resisting
structures.

The Fetal Body. — The head is by far the most important
anatomical division of the fetal body in labor, on account of its
bulk and density. The fetal head may be divided into the
yielding and the unyielding portions. The former consists of
the cranium, composed of the two frontal, the two temporal, the

Fig. 209. — Diagrams illustrating the lateral ''pull " and **push" on the cervix.

two parietal, and the occipital bones. These bones are separated
from each other as follows : The two frontals by the frontal
suture, the frontal from the parietal by the coronal suture, the
two parietal by the sagittal suture, and the two parietal from
the occipital by the lambdoidal suture. At the junction of
the lambdoidal and the sagittal sutures there is a membranous
space, called the posterior fontanel, triangular in shape. At the
junction of the frontal, coronal, and sagittal sutures there is
also a membranous space, called the anterior fontanel, kite-
shaped, and larger than the posterior fontanel. This portion
of tlic skull, the cranium, yields to pressure, and is reduced in
si/.c by an ovcrlappin<^ of the bones.

The unyielding portion of the skull comprises the face and
the base of the skull. The bones of this region are fixed and
unyielding.

A transverse vertical section of the skull is somewhat wedge-
shaped, the wedge tapering toward the neck. A longitudinal
medial section is distinctlv conical in form.

MECHAS'ISM OF PRESETS

35i

Possible Presentations of the Head. — Vertex. — By this term is
meant that conical portion of the skull with its apex at the
smaller fontanel and its base at the planes of the biparietal
and trachelobregmatic diameters, — tlu- face ; the brow ; the
larger fontanel ; tlu- parietal e?niHenee ; the ear.

The Mechanism of Labor in a Vertex Presentation and a
Left Oceipi to-anterior Position. — It is convenient to begin the
study of i-ach presentation with a consideration of its diagnosis.

The diagnosis of position and presentation is made by abdom-
inal palpation, auscultation, and vaginal examination. By these

methods of examination in the position and presentation under
discussion the fetal back is found to the left, the extremities to
the right and above, the head below ; the heart -sounds are heard
most distinctly about an inch below and to the left of the umbili-
cus; the e-xamining finger in the vagina detects the vertex pre-
senting, with the occiput directed toward the left acetabulum ; the
sagittal suture is in the right oblique diameter of pelvis ; the
smaller fontanel, recognized by the junction of the lambdoidal
and the sagittal sutures as the most dependent portion of the
presenting part, and the tip of the occipital bone, overlapped by
the parietal bones. As the direction or axis of the pelvic canal
diverges from that of the uterine cavity, running, at first, more

3S8 THE MECHANISM OF LABOR.

posteriorly, there is usually a lateral inclination of the head so
that the sagittal suture is posterior to the normal position of
the oblique diameter of the pelvis, and one parietal bone (the
anterior) is deeper in the pelvis than the other one.

The mechanism of labor in a left occipito-anlcrior position
of a vertex presentation may be taken as a type of the mechanism
of all labors, the variations in the process imposed upon it by

the dificrent positions and presentations of the fetus being readily
understood if the typical mechanism of the commonest presenta-
tion and position is thoroughly mastered.

It is convenient to divide the mechanism of labor into a
number of steps or acts, as follows :

First Step. — Accommodation of the size of the fetal skull to
the size of tJie pelvic canal by flexion ; accommodation of the shape

MECHANISM OF PKESEXTATIONH AND POSITIONS. 359

-^, -

X 1?, .,

Fig. 1X1. — Gcnitil tnicl wllh fetiu leiuuved, sliawiog divuigeace of the pelvic
axis rrom thai of the ulerine civily : a, n, Mcmbroues ; b, b, contraction ring ; i", c,
nainl down lo which nientbriuies are unacparaletl ; i/, promontory : r, region of oi
inlcnium (alHiie whicli fragments uf riecidua are fuunil, and below it cervical glands] ;
/, liulging of wall inlri neck af felus ; g, g, os eileniuin ; A, pouch of Dooglas ;
I, posterior vaginal wall (elongnttil aud thinned} ; j, rectum ; i, stretched anal canal :
/, (ilacenta ; m. alemve?ii.:il ]i<^iiloneam i n, region of os Inlemiun (above which
fragmcnls of ineniliranc. art- toiiti^l, and below it tx>rtionsol cervical glands) ; c, lower
limit of bladder; /'.anlcrioi- vjginal wall (not elongaledi; •/, iirclbra; r, vagina;
I, vulva ; /, perineum with blood eMr^ivaiiatiDn (Katbour and Webster),

360 THE MECHANISM OF LABOR.

of the fetal skull to the shape of the pelvic inlet by molding;
accommodation of the direction of the head to the direction of
the pelvic canal by lateral inclination. These movements occur
prior to labor, when the head enters the pelvic inlet with the
subsidence of the uterus.

Second Step. — Further flexion, molding, and accommodation
of the head to the pelvis by lateral inclination, when labor -pains
appear, and the head is subjected to a propulsive force and to

uterine segment, the cervix, and the
uterine cavity and of the

the resistance of the l
pelvic walls.

Third Step. — Dilatation of the low
cer\'ica! canal.

Fourth Step. — Descent of the head to the pelvic floor, mainly
by an extension of the fetal spine. The fetal body, as a whole.
is not yet propelled along the birlli-canal. because, during a pain
and while the head is obviously descending to the pelvic floor,
?' •^ and the breech do not sink to a lower level.

MECHANISM OF PRESENTAT/OXS AND POSITIONS. 361

On the contrary, there is a slight elevation of the fundus, an
elongation of the uterus, and the distance between the head and
the breech increases during a uterine contraction.
Fifth Step. — Anterior rotation of the occiput.
The Cause of This Moi'i'tiicnf. — The head, driven through the
funnel-shaped parturient canal, its most dependent portion, the
tip of the occiput, first strikes the resistance of the upper portion
of the pelvic floor, which is represented by a curved line or plane
running inward, downward, and forward. These directions are

imposed, therefore, upon any movable body impinging upon the
pelvic floor and impelled by a force from above. The occiput
can only travel in ^ic directions named by a rotary movement
of the head upon the spine.

Sixth Step, — Propulsion and extension of the head in the
direction of least resistance under the pubic arch until it is deliv-
ered, again following the direction of the lower pelvic floor,
which is now upward, forward, and outward,

Seventh Step. — Restitution. The rotary movement of the

362

THE MECHANISM OF LABOR.

Fig. 215. — Tiic roiatiuiiof tlie liL-aU liciiig cuini>li--lril, its piojjiilsioii forwaiii 1

■BCHANISM OF PRESENTATIONS AND POSITIONS. 363

head, previously described, is not followed by the shoulders. As
the former escapes from the vulva with the sagittal suture running
anteroposteriorly, the neck is necessarily twisted. As soon as
the head is released from the forces which compel its rotation, it

Fig, 317.— Birth of ihe shouUt

immediately resumes its natural relationship M'ith the shoulders,
which lie with their long axis in the oblique diameter of the
pelvis.

364 THE MECHANISM OF LABOR,

Etehth Step. — External rotation. This movement of the
head is explained by the movement of the shoulders within the
birth-canal.

Ninth Step. — Descent, rotation, and birth of shoulders.

The anterior, or right, shoulder first strikes the resistance of
the pelvic floor. In obedience to the universal law already
enunciated, that whatever portion of the fetal body first encoun-
ters this resistance is directed downward, forward, and inward,
the anterior shoulder is compelled to travel in these directions
by a rotary movement of the shoulders on the spine.

The anterior shoulder finally appears under the arch of the
symphysis ; unable to move further forward, the posterior
shoulder and arm are propelled over the floor of the pelvis and
are born, their escape being followed by the birth of the anterior
shoulder and arm.

Tenth Step. — Delivery of remainder of the body by a move-
ment so rapid that the eye can not well follow it, the birth-canal
being so widely dilated that its walls offer no resistance to the
escape of the small and compressible thorax, abdomen, and lower
extremities.

ABNORMALITIES IN MECHANISM AND THEIR MANAGEMENT.

Abnormalities of Flexion at the Inlet. — Imperfect Vertical
Flexion in a Flat Pelvis. — This action is conservative on the part
of nature, and has the effect of bringini^ the small bitemporal diam-
eter (8 cm. — 3^ in.) in relation with the contracted conjugate.
Associated with this abnormality are found anomalies of position
and lateral flexion. The head lies transversely, the sagittal
suture running in the transverse diameter of the pelvis, and the
lateral flexion is exaggerated as the result of the increased
obliquity of the pelvis, the increase of the conjugatosymphyseal
angle and the posterior parietal bone catching on the promontory.
The exaggerated lateral inclination of t!.c head is accompanied
by overlapping of the right (anterior) parietal bone. In much
exaggerated lateral flexion the anterior parietal bone, or even
the ear, may present. In exceptional cases (one-tenth) the pos-
terior parietal bone may present in consequence of the anterior
portion of the head catching upon the pubic spines. These
anomalies of mechanism require no treatment, as a rule. They
should not, indeed, be interfered with, as only by these means is
the obstacle of a contracted pelvis to be obviated spontaneously.
It is, however, occasionally necessary to interfere on account of
exaggerated lateral inclination. A presentation of one ear may
demand podalic version. A less exaggerated lateral inclination,

ABNORMALITIES IN MECHANISM. 365

especially in case the anterior parietal bone catches on the
pubis, is ordinarily easily dealt with by using one blade of the
forceps as a vectis to pry down the retarded half of the head.

Anomalies of Direction. — In anterior displacements of the
parturient uterus there is an abnormal backward direction of the
presenting part, and in lateral tilting of the uterus the presenting
part is directed to the opposite wall of the pelvic inlet and canal.
All progress may cease as the head butts in vain against the un-
yielding pelvic walls. An abdominal binder corrects the anterior
displacements. Placing a woman on that side toward which the
fundus uteri is tilted and putting under her flank a rolled blanket
or pillow corrects the lateral displacement.

Anomalies of Rotation. — There may be abnormal weakness
in resistance or propulsion, resulting in incomplete rotation.
Anomalies of rotation are more important in cases of posterior
positions of the occiput.

Anomalies in Vertical Flexion at the Pelvic Outlet. —
Flexion may be incomplete if the head does not encounter normal
resistance in the pelvic cavity or upon the pelvic floor, or it may
be exaggerated, in which case the vertex impinges on the center
of the perineum and may perforate it. Both of these anomalies
may be corrected by applying the forceps and lowering the
handles for incomplete, raising them for overflexion, as the
woman lies upon her back.

Anomalies of Extension and Forward Propulsion. — Failure
of extension and of a forward propulsion of the head under the
pubic arch occurs as the result of weakness of the pelvic floor,
in consequence of destruction of the levatores ani muscles in a
former labor. Paradoxical, therefore, as it may sound, a lacera-
tion of the pelvic floor in one labor may predispose to further
lacerations in the next.

Anomalies of Restitution. — This movement is more or less
theoretical and is rarely perfectly performed. It fails altogether
if the neck is a long time twisted or is tightly gripped by the
ring of the vulvar orifice.

Anomalies of external rotation are due to an imperfect or
anomalous rotation of the shoulders. They are of frequent
occurrence.

Anomalous Descent and Rotation of Shoulders. — Rarely
the anterior shoulder is caught at the pelvic brim and does not
descend. The posterior shoulder is then the first portion of this
part of the fetal body to encounter the resistance of the pelvic
floor. It is consequently turned forward, inward, and downward,
the head externally following this movement and turning un-
expectedly with the face to the left and the occiput to the rights

366 THE MECHANISM OF LABOR

though it had descended the birth-canal and escaped from the
parturient outlet in a left occipito-anterior position.

Mechanism of a Ris^ht Occipito-anterior Position of a
Vertex Presentation. — Dias:nosis. — Palpation reveals the back to
the right anteriorly ; the extremities to the left above ; the head
below. The heart-sounds are heard near the median line, below
the umbilicus. Digital examination shows the small fontanel
toward the right acetabulum ; the sagittal suture in the left
oblique diameter of the pelvis.

The mechanism of this position does not differ from the
mechanism of the L. O. A., except in that the occiput being
directed toward the right acetabulum, the rotation of the head
and face takes the opposite direction, — that is, the occiput rotates
anteriorly, moving from right to left.

The Mechanism of Posterior Positions of a Vertex Pres-
entation, R. O. P. and L. O. P. — Posterior positions of the
occiput are primary or acqidrcd. They are primary if the head
enters the inlet with the occiput posterior. They are acquired if
the head rotates from an anterior position at the beginning of
labor to a posterior position at its close. Acquired posterior
positions of the occiput are very rare.

Dias:nosis. — Palpation reveals the fetal back in the maternal
flank (to the right in R. O. P., to the left in L. O. P.). The ex-
tremities are found on the opposite side in front, the head below.
The heart-sounds are heard in the flank below a transverse line
through the umbilicus. Digital examination shows the small
fontanel toward the right or left sacro-iliac joint ; the sagittal
suture in an oblique diameter of the pelvis.

The mechanism is the same as the mechanism of anterior
positions, including anterior rotation of the occiput under the
arch of the symphysis. As a consequence, however, of the pro-
longed rotation of the occiput, sweeping over about one-third of a
circle, a peculiarity in the mechanism is the rotation of the
shoulders at the .superior strait through a third of a circle, — a
movement not seen \\\ anterior positions. And, further, in con-
sequence of the greater distance which the occiput must traverse,
the clinical manifestations of this position are different, — there is
greater pain, and labor is more prolonged. After rotation has
occurred the shoulders descend and rotate on the pelvic floor, as
in anterior positions. The remainder of the mechanism is identical
with that of anterior positions.

The cause of tlie forward rotation of tlie occiput is the same
as it is in anterior positions, — namely, whatever portion of the
fetal body first strikes the resistance of the pehne floor ^ witether it
encounters this structure be/und or in front of the median transverse

ABNORMALITIES IN MECHANISM. 367

iite, is /directed forward, inward, and downward, under the
irih of the symphysis. As the occiput is the most dependent
Dart of a vertex presentation, it must first encounter the resistance
af the pelvic floor, and must, accordingly, be rotated in the direc-
ions named.

)ut complicates labor by protracting its course, increasing the

danger of fetal death, and subjecting the mother to increased risk

of injury.

The causes may be divided under three heads :

Anomalies of Force. — Anterior rotation is the resultant of the

brces of expulsion and resistance ; hence, any condition disturbing
he normal relation of these forces interferes with the norma

rotation. Thus, backward rotation occurs if there is dimin-

shed expulsive power, increased resistance or decrease in re
sistance. as occurs in cases of very large pelves, relaxed pelvic
floors, small and yielding heads.

Anomalies of Flexion. — If flexion is imperfect, the anterio
vault of the cranium (as in those rare cases of presentation of
the large fontanel), the brow, or the chin frsl strikes the pelvic
floor, and is. therefore, directed forward, and the occiput is thus
directed backward.

hisuperablc Obstacles to Fanvard Rotation. — In some cases if
flexion is only fairly good, and the occiput does first .strike the pel
vie floor, the occiput rotates backward, because the lai^e diam
eter of the head (fronto-occipital, 1 1 3'4 cm. — 4^5 in.) is engaged
and rotation from one oblique diameter of the pelvis to the othe

ABNORMALITIES IN MECHANISM. 369

contracted, and Naegele's pelves, the occiput rotates backward.
If there is an abnormal projection of the lumbar and sacral
vertebrae, interfering with rotation of the shoulder, the head
may not be able to rotate anteriorly. Rarely there may be
rotation of the head without a corresponding movement of
the body, and the result is an exaggerated torsion of the
neck. I have seen a child fatally injured in this manner.
In most of the reported cases, however, the infant has escaped
unharmed.

The iVIechanism of Lat>or when the Occiput Rotates into the Hollow
of the Sacrum. — The occiput is propelled forward over the peri-
neum by increased flexion until the face is finally born under the
symphysis by partial extension. This mechanism subjects the
cranium of the fetus to dangerous pressure, and greatly increases
the risk of perineal rupture by subjecting the structures of the
pelvic floor to an enormous strain.

Abnormalities in the iVIechanism Just Described. — There may be
abnormal resistance to the descent of the occiput, resulting in
a conversion of the presentation into one of the large fontanel,
brow, or face, by an extension of the head.

As causes of this anomaly, projecting ischiatic spines or a
central tear of the perineum have been reported.

Treatment of Posterior Positions of Vertex Presentations. —
The medical attendant must bear in mind the causes of backward
rotation, and should try to prevent its occurrence. For this pur-
pose it is essential to secure perfect flexion of the head by placing
the patient on that side toward which the fetal back is directed,
and to obtain a normal action of the expulsive and resisting
forces. If the pelvic floor is weakened, and does not supply
sufficient resistance, it should be reinforced by two fingers in the
vagina or by a single blade of the forceps, imitating the shape
and direction of the pelvic floor. If the expulsive power is faulty,
a single large dose of quinin may be administered, or forceps
may be applied. If backward rotation occur in spite of the
precautions to prevent it, extraordinary care should be exercised
to protect the vaginal walls and the perineum from laceration,
and to avoid a protracted second stage of labor. These results
can usually be accomplished by a judicious use of the forceps.
It might be an advantage, in rare cases, to convert the vertex
into a face presentation by retarding progress of the occiput and
assisting the extension of the head.

Prognosis. — ^The outlook is not so favorable as it is in

anterior positions of the occiput. The forceps is often required

(once in seven cases). Laceration of the maternal soft parts is

much more frequent. The mortality of the fetus is increased

370 THE MECHANISM OF LABOR.

from less than S P^"" cent (the average mortality of normal
vertex) to more than 9 per cent

Fortunately, backward rotation of the occiput in vertex pres-
entations occurs in only about 1 J^ per cent, of all labor cases.

Face Presentations. — In this presentation the head is ex-
tremely extended. The chin is the most dependent aijd prom-
inent portion of the presenting part ; hence the positions arc
named by its relations to the maternal structures, as left mento-
anterior, right mento-anterior, etc. Every face presentation be-
gins as a presentation of the brow, the extreme extension only
occurring when the head is subjected to the action of the uterine
pains and the resistance of the walls of the genital canal.

Frequency Face presentations occur about once in 250

labor cases, or in less than 0.5 per cent

and rigbt meDtapoMerior

fHasnosls. — The unusually prominent bulk of the cranial
vault is felt in one hypogastric region ; a deep groove between
the occiput and thu child's back may often be made out The
fetal heart-sounds are loudest over the anterior surface of the
fetus, or on that .siilc of the maternal abdomen upon which the
fetal extremities are felt. The diagnosis, however, must usually
rest on a digital examination, which shows before the onset of
labor a high situation of the presenting part ; a flattening of
the anterior vaginal vault ; a sharp contrast between the smooth
outline of the fetal forehead and the irregular contour of the

BiVOEMAL/riES IN MECHANISM.

371

&ce. As soon as tho os is dilated, the characteristic features of
the face may be felt. A face presentation has often been mis-
taken for a presentation of tht bretch, The orbital ridges, the
eye-sockets, the chin, and. most distinctive of all. the hard
gums within the mouth, should enable any one to make the
differential diagnosis. This presentation should be considered
as a pathological one, for it entails great danger upon both
mother and child.

The causes of face presentations are divided under three heads,
as follows : ( I ) Conditions preventing flexion, as tumors of the
neck ; increased size of the thorax ; constriction of the cervix
about the neck ; coiling of the cord around the neck ; tonic
contraction of the neck muscles.

Fig. 211.-Y

(2) Conditions favoring extension, as mobility of the fetus;
oblique position of the child and uterus, especially when the
abdominal surface of the child is directed downward and the
pelvis is fiat ; a dolichocephalic head, in which the posterior
segment of the skull is longer than the anterior; tumors upon
the back, as spinal meningocele. Causes which promote exten-
sion of the trunk and shoulders, and consequently of the head.
as an overfilled bladder of the mother pressing upon the child's
back. After the head has descended into the pelvic cavity, the

372 THE MECHANISM OF LABOR,

face presentation may be due to the conversion of an occipito-
posterior position into that of the face, as already described.

(3) Anything that interferes with the normal engagement of
the head in the pelvis, as overgrowth of the fetus, deformed
pelvis, pelvic tumor.

The iVIechanlsm. — The successive steps of the mechanism of
labor in a face presentation occur in the following order :

Extension. The head presents at the superior strait imper-
fectly extended, so that every case of face presentation may be
said to begin as a brow presentation. There is also at first
imperfect engagement of the presenting part, on account of the
large diameters presented at the superior strait. Under the
influence of the expulsive action of the uterus and the resistance
of the pelvic walls, the brow, caught upon the pelvic brim, is
held stationary, while the chin descends lower and lower by an
extreme extension of the head.

Molding, or an accommodation of the shape of the presenting
part to the shape of pelvis, occurs to a moderate degree or not,
all because the face is a loose fit in the normal pelvis. The
molding is confined to the back of the skull.

Lateral inclination is a constant feature, so that one cheek is
a little deeper in the pelvic canal than the other one.

Descent of the presenting part follows the dilatation of the
cervical canal, the descent of the chin being accomplished almost
solely by the extension of the head, and not by a descent of the
head as a whole.

Anterior rotation of the chin occurs as soon as it encounters
the resistance of the pelvic floor. Anterior rotation is followed
by the engagement of the chin under the symphysis pubis.

Then follows the delivery of the head by flexion and propul-
sion, the mouth, nose, eyes, and forehead sweeping over the peri-
neum and appearing successively at the posterior commissure.

Restitution and external rotation follow the escape of the
head from the same causes that impose these movements upon
the head in a vertex presentation. The delivery of the body
takes place as in a vertex presentation.

Abnormalities in Mechanism. — The most common and most
important anomaly of mechanism is a delay in the forward
rotation of the chin under the symphysis. This delay is
due to the difference between the lateral depth of the pelvis
(8.8 cm., ox lYi in.) and the length of the fetal neck (3.8 cm., or
I J^ in.), as a consequence of which the chin may not encounter
the necessary resistance to turn it forward, and without this for-
iff^xA mow*»«ru»nf it is impossible for the head to escape through

lid the chin be directed posteriorly, where

ABXOHMALITIES IN MECNA.VISM. 373

^L^K^ J

^^■f^^^H

sM J^^^^^l

2.— Face ijresentalion, chin .lirccttd lultrally.

374 THE MECHANISM OF LABOR.

the depth of the pelvis is even greater (5 inches), the delay is
absolute, and such cases can only be terminated by artificial
assistance. If the condition is left to nature, there is an effort
to force the upper portion of the thorax (g cm.) into tlic pelvic
cavity, along with the posterior half of the child's skull
(9}^ cm.), for only thus can the chin descend sufficiently to be
turned anteriorly under the pubic arch, but it is obviously impos-
sible for the bulk of these two diameters to pass through the pelvis.
If the chin is posterior, it may rotate to a transverse position, and
then all progress may cease, because the occiput catches on a
shoulder and so further extension of the head is prevented (Figs.
225, 236. 227V

'loDgalion of neck.

Prognosis. — The fetal mortality of face presentations is 13 to
I s per cent. The maternal mortality rises from less than I per
cent in all labors to 6 per cent, or over, if one takes into account
cases of anterior and posterior positions and those which are
mismanaged or neglected in general practice.

Treatment. — If the chin is directed well forward of the trans-
verse diameter of the pelvis, the Jabor may require no inter-
ference. In posterior positions of the chin, however, the
case is always difficult, and demands active treatment. Before
jarly stages, the face presentation may be

ABNOJiMAUriES iX .MECIIAKISM. 375

Fig. JI7. — Face prescntalion.

376 THE MECHANISM OF LABOR.

converted into one of the vertex by the method of Schatz —
external manipulation (see Fig. 228). By combined pressure
upon the breech by an assistant, and upon the anterior wall of
the thorax and the occiput, the fetal body is flexed and flexion

Kig, 228. — Schaiz's melhod of cephalic

of the head is secured. If this plan fail, the methods of Bau-
delocque (internal and external manipulation) should be tried
(see Figs, 229, 230, 231). The chin is pushed up by the inter-

?x presCDtBliOD (Baudelocque).

wWte t^ <>cciput is pressed down by external pressure,

i jlown by the internal hand, while exter-

* ■■ i's body. This attempt also fsiX-

', if the face is not impacted in

ABNORMALITIES IN MECHANISM. 377

Fig. 330. — The conTcrston of a face in(o a verlcx presenlation (Baudelocque).

Fl(. 131. — The conTcision of r face inio a vertex presentation (Uaudclocque),

378 THE MECHANISM OF LABOR.

the pelvis. While labor is in progress, care should be exercised
not to rupture the membranes, that the os may be more thor-
oughly dilated and the liquor amnii shall not be drained away.
If the presenting part is impacted in the pelvis, and if anterior
rotation of the chin is delayed, it may be hastened by two fingers
pressing on the posterior cheek and chin, supplying the kind and
shape of resistance that should be afforded by the pelvic floor,
which the chin can not reach ; or, if more convenient, pressure
may be applied with a single blade of the forceps. If anterior
rotation can not be effected in this manner, a straight forceps
may be used to compel rotation by twisting the head, and, if the
chin is directed anteriorly, traction may be made upon the for-
ceps. If the chin is directed backward, traction should ncifer
be attempted. Finally, after failure of efforts to convert the face
presentation into a presentation of the vertex, to perform version
and to rotate the chin craniotomy is necessary.

At the last part of the second stage of labor care must be
exercised in the final delivery of the head, not to push the neck
too forcibly against the symphysis while trying to prevent lacera-
tion of the perineum.

Presentation of the Brow. — In this presentation the head
remains throughout labor midway between complete extension
and complete flexion. Therefore, the largest diameters of the
head present at the superior strait. Of all presentations of the
head this is the most unfavorable for both mother and child.
The four positions of the presentation are named according to the
direction of the chin.

Frequency. — In Guy's Hospital there were 14 brow pres-
entations among 24,582 births (i m 1756).

The diag:nosis is made by digital examination. It would be
practically impossible to distinguish by abdominal palpation the
difference between a face and a brow presentation.

Mechanism. — The steps of the mechanism are the same as
those of a face presentation. If the chin is directed posteriorly,
progress is impossible, for the same reasons that make a poste-
rior position of a face presentation an insuperable obstacle in labor.

Progrnosis. — The fetal mortality has been computed to be
thirty per cent. ; the maternal, ten per cent. The latter, however,
depends entirely upon the woman's treatment. Competent man-
agement should insure the mother's safety.

Treatment. — Before labor, or in its early stages, the brow
should be converted into a vertex presentation. This can some-
times be accomplished by external pressure on the occiput to
secure flexion, as in Schatz's method of treating a face pres-

n fail, the hand may be inserted into the

AB.S-OHMAUTIES IN AfECI/AXISAf.

379

vagina and uterus to pull the occiput down. Should this
attempt not succeed, it would be best to convert the brow into a
race presentation if the chin is anterior. Failing in tliis, version
should be tried if the waters are not drained off or If the present-
ing part is not fixed in the superior strait. If the chin is anterior
and the presenting part is firmly fixed in the pelvis, the appli-
cation of the forceps usually succeeds ; if the chin is posterior,
and if conversion into a vertex presentation, performance of
version and rotation are all impossible, craniotomy is indicated.
In face and brow presentations with the chin posterior, it is a
cardinal rule not to use forceps except as rotators ; if traction is
resorted to at all, even in mento -anterior positions, it should be
employed with the greatest caution and gentleness. Ilrj' rarely

tig. ^J.

the head may be brought down far enough to meet with resist-
ance, and tlius be rotated anteriorly ; but unless the head yields
to moderate traction, embryotomy is preferable.

Presentation of the Greater Fontanel. — ^The head in this
very rare presentation is set squarely upon the shoulders in a
sort of military altitude of attention, turned upside down. In
its clinical features this presentation resembles that of a brow.
The descent of the head is difficult and tedious ; the anterior
(frontal) portion rotates forward, but with great difficulty, and
serious injury to the maternal soft parts is almost unavoid-
able. The stretching of the vaginal walls is so great that
the perineum may be lacerated into the rectum before the head
has fairly impinged upon the pelvic floor.

380 THE MECIfAXJS.\f OF LABOR.

Treatment. — The abnormal position of the head should be
altered into a vertex presentation by pulling down the occiput
with the fingers or by pushing up the brow while pressure is

fjb^

made upon the occiput from above through the abdominal
walls.

ABXORMALITIES IN MECHANISM. 38I

Presentation of the Breech. — By a presentation of the
breech is meant a presentation of any part of the pelvic extrem-
ity of the fetal ellipse. The term, therefore, includes a presenta-
tion of the nates, thu knees, or the feet. The classification of
the positions is made by the direction of the sacrum, as a left
sac ro- anterior, right sac ro -anterior, etc.

Frequency. — Breech presentations occur in 1.3 per cent, to 3
fjer cent, of all cases, the first figures referring to mature births
alone.

Causes. — Abnormalities in the sha[>e of the fetus or in that
of the uterine cavity are the chief causes of a breech presenta-
tion. Included under this head are reversal of the uterine ovoid
(the lower uterine segment larger than the upper), fetal monstrosi-
ties, twin pregnancy. Increased mobility of the fetus accounts
for a small proportion of the cases, especially in premature
births.

Diagnosis. — By abdominal palpation the head is found above,
the breech below. The heart-sounds are heard above the level
of the umbilicus. Digital examination shows a high position of
the presenting part ; an absence of the dome-like projection of
the vaginal \'ault which is found in a presentation of the head ;
the bag of waters projects tlirough the os as a pouch-like protru-
sion ; by pressure on the fundus with the external hand the
characteristic features of the breech may be detected — namely,
the nates and the sulcus between them, the tip of the sacral bone
and the coccy.\, the thighs, the external genitalia, and the anus.
Evacuation of meconium is the rule in a breech presentation ;
so that the examining finger is found stauied with it, after the
membranes have ruptured.

The Mechanism of Ljibor, — The following steps are to be
noted : Dilatation of the cervix and descent of the breech to
the pelvic floor. This occurs very slowly, because the soft
breech is an imperfect dilator of the cervix and an ineffectual
irritator of reflex uterine contractions ; hence many hours may
be required for the first stage of labor. Rotation forward of the
anterior hip, which is the first to encounter the resistance of the
pelvic floor. Owing, however, to the insufficient resistance
which the soft breech encounters, its rotation is imperfect.

There then follows the birth of the anterior hip. posterior hip,
the thighs, and the trunk. The next and a very important step
is the engagement and descent of the shoulders in an oblique
diameter of the pelvis. The anterior shoulder, first encountering
the resistance of the pelvic floor, is turned forward under the
pubic arch. Then occurs the birth of the anterior followed by
that of the posterior shoulder. The head by this time has

382 THE MECHANISM OF LABOR.

I Vvg. aj5. — Btecch iirescmation , Irft ^ncronnlerior posilloo.

\ORMAL/T!ESi IX A/Ea/AX/SM. 383

tig. 137 — Breech preunUlioas, aiileriot luid poslerior p.

1 3^4

TI/E MECHANISM OF LABOR.

t FiB. ;jS.-

Snme ns lieurp 337, sliowing dcscenl af breuch fhrounh Ihe |

«1vic canal. ■

r ng. ^39-

Same ih liguic 2J7. shuHing png]igemtnl of the shoulJers i

iiir peiiii. 1

ABNORMALITIES IN MECHANISM- jSj

Kig. 240. — Same ns li)jiire 237, ^bowing estape of

ig. 241. — lirccth preicnlalion^rrjimjan of llie tups.

THE MECHANISM OF LABOR.

entered the pelvis with its long diameters in the oblique diameter
of the pelvis, opposite to that in whicli the shoulders engaged.
The head descends the birth-canal to the pelvic floor in a
position of extension. The occiput, which is always the part
first to strike the pelvic floor, is rotated forward under the

n X-para at full term.
wliD ilied from hemorrhage Hjme boufs after both her legs bud been cut off by a locu-
motive: a. First lumbar vertebra; *, placenta; <-, fractured first »ncral vertebra; .r,
coronary vein i e, blood exlravasatiou ; f. poucfa of Douglas; g. cervical canal; k.
03 externum ; r, tectum ; j, umbilicus ; t. o% internum ; I, uterovesical reflection of
peritoneum; w, bladder; m, symphysis pulii« ; n, vagina.

pubic arch. There follows then the delivery of the head in the
following order : Chin, face, forehead, anterior fontanel, sweep-
ing successively over tlie ijerineum and appearing in the vulvar
orifice.

Prognosis. — The fetal mortality of breech presentations is
about thirty per L.Liii , iiicUuIiiij; badly managed cases in gen-

ABNORMALITIES IN MECHANISM.

387

eral practice. There is some added danger of injury to maternal
soft parts, on account of the necessity for rapid and sometimes
violent extraction of the after-coming head.

Treatment. — Before labor external version may be attempted.
It will not always be found practicable, and after the fetal body
has been turned there is a disposition on the part of the fetus to
resume its original position. The application of two long cylin-
drical compresses to the sides of the uterus, and a firm abdomi-
nal binder, may prevent a return of the breech presentation.
When labor has begun, inaction should be the physician's policy
until the fetal body is bom to the umbilicus, unless maternal or

Fig. 243. — Delivery of ihe nfler coming

fetal life is threatened or an indication for rapid delivery arises.
As soon as the trunk appears the patient should be placed in the
lithotomy position across the bed, and delivery of the shoulders
and head should be effected by pressing upon the fundus with one
hand, the other hand being inserted in the vagina to favor anterior
rotation of the shoulder, anterior rotation of the occiput, and to
direct the pass^e of thu head through the vagina (Wiegand's
method : see Delivery of the After-coming Head).

Abnormalities In Mechanism. — The most frequent and impor-
tant anomalies are backward rotation of the occiput and excess-

388 THE MECHANISM OF LABOR.

ive rotation of the breech. Backward rotation of the occiput
is very exceptional. The mechanism of the delivery of the head
in these cases diflers as the head remains flexed or becomes
extended. When flexed, the chin, face, forehead, and anterior fon-
tanel slip out under the symphysis in the order named, and the
head is delivered. When extended, the chin catches upon the
symphysis, the head is extremely extended and is bom by the
occipital protuberance, small fontanel, cranial vault, and face
slipping over the perineum. The following rules for managing
the extraction of the head in these cases should be remembered:
If the head is flexed, the body of the child should be carried
downward ; if it is extended, the body should be carried upward
over the mother's abdomen. Excessive rotation of the breech
occurs as the result of a prolapse of a posterior extremity, and
is of no great practical importance.

Fig. 244, — Chin arrested at symphysis; head eitended (Cha illy -Honor*).

The Mechanism of Shoulder Presentations. — A transverse
position of the child in utero almost always resolves itself into
a shoulder presentation as the result of uterine contraction when

labor begins. Presentations of the umbilicus (Fig. 253) and of
the back (I'igs. 250, 25 1) arc possibilities, but are extremely rare.
Shoulder presentations are classified according to the positions
of the back and head. When the head is to the right, the back
may be in front or behind. The same is true when the head is
to the left. The back is directed anteriorly twice as often as
posteriorly, and the head more than twice as often is found
toward tlie left-hand side of the niateniai pelvis.

Diagnosis. — Abdominal palpation reveals the fetus in a trans-
verse position. The hcart-.sounds are more distinct at a point
corresponding to the inter.sca])ular region of the child, but some-
times can not be heard. A digital examination shows the
characteristic anatomical peculiarities of the shoulder and adja-

ABKOHMALniFS IN ^tFCffAXISM. 3S9

y'Z- l4S.-Sl"">l'1"r

(■iy, 246, — Shoulder pi

390 THE MECHANISM OF LABOR.

Y\f, 248. — Shoulder ptesenta^i

ABiVOA'MALIT/ES I.V MECJ/AXJS.yf.

Fig. 249. — Tiaiiiverse pusilion of the fell

Fig, 150, — Batk presenLnL
tbe left um i» projecling. llie tr
Terse furrow gites Ihe appearam
tbmch iiresenLalion (Budin).

Fig. 151,- lu... ,
Iwo arms ptoJKCtiuu iii
genital organs (Budin).

392 THE MECHANISM OF LABOR.

Fig- ^SJ.-P'"''""""'" "f tl"^ "'"'''li

ABNORMALITIES IN MECHANISM.

393

cent parts — namely, the axilla, the clavicle, the spine of the
scapula, the acromion process, the head of the humerus, and the
ribs.

Causes. — The causes of a shoulder presentation may be
divided under three heads : (i) Abnormalities in the shape and
position of the uterus, as a pendulous abdomen ; a uterus
bicomis ; the broad uterus accompanying a kyphotic spine ;
the distorted uterus due to uterine fibroids and other abdominal
tumors, and to multiple pregnancy. (2) Conditions preventing

Fig. 254. — Spontaneous evoli

engagement of the cephalic or the pelvic extremity of the fetus,
as deformities of the pelvis ; abnormally large child ; monstrosi-
ties ; placenta previa, (3) Abnormal mobility of the fetus, as
occurs in hydramnios, after fetal death, or in premature births.

Mechanism. — Strictly speaking, there is no mechanism of
shoulder presentations. The course of these cases is impaction
of the shoulder, enormous dilatation of the lower uterine seg-
ment, ascension of contraction-ring, destruction of the fetus by
prolonged pressure, and death of the mother by rupture of the
uterus or by exhaustion. As a matter of fact, however, nature

can, in very exceptional
methods :

TJIE MEd/A.V/SM OF LABOR.

cfiect delivery by one of three

Fig. 155. — Rare form of mcchnnism, Fig. 256.— Impending ru|ilure

known as birth wilh doubled body (one- of ulenu in nshoulderprescDWlion :

lixth natuni silc, redrawn from Kiismer). ee. Eilemal os; ui, inlemal 05;

f , coturaction-ring (much modified
from Sqhroeder).

Spontaneous version. The transverse position is converted
into a longitudinal position by the uterine contractions.

Spontaneous evolution. The breech slips past the shoulder

ABXORMALiriF.S IN MECHANISM.

39S

and is delivered first, the rest of the body following as in a
breech presentation.

The body doubled up (corpore reduplicato) is expelled in
one mass. This termination is possible only in premature births
with a small child, usually macerated.

Treatment. — The treatment of shoulder presentations may
be summed up in a single word — version. If the child is dead ;
if the shoulder is tightly impacted and the lower uterine segment
is so distended that the slight additional strain upon its walls of
turning the child will probably determine a rupture of the uterus,
the child should be decapitated.

MECHANISM OF THE THIRD STAGE OF LABOR.

The mechanism of the third stage of labor is divided into two
acts — the separation and the expulsion of the placenta. The
most probable explanation of placental separation is found in the

I V-pan who ilied
bnm u^lap&e (niplure of uterus wilb hemoiTfaiige) sbortlf Rfter the expulsion oflhe
felns : a. Fundus uteri ; A, memliraiics still ■lltcUed j f, retraction- ring : d. lelniplBcen-
■•1 blood-clot : f, inverted plocenli ; f, contniuled oe eitemum ; g, cord presenling.

theory of a diminution in the area of the placental site, which the

a follows to a certain point, when, becoming solid by the

approximation of the villi and the obliteration of the lacun:e, it

396 Tim MECHANISM OF LABOR.

can no longer follow the contraction and retraction of the uterus,
and is sprung off from the uterine wall. It requires usually
several pains to accomplish this result ; so that the placenta is
not, as a rule, completely detached until about fifteen minutes
after the delivery of the child, when it may be found lying in
the dilated pouch of the lower uterine segment and cenical
canal. The walls of this portion of the birth-canal are so flaccid
from pressure paralysis and ovcrdistcntion that the placenta

Fig. aS9,

might remain there many hours, perhaps days, unexpelled.
Hence it is tliat artificial assistance is almost always required
to express the placenta, The placenta is usually expelled like
an inverted umbrella, the fetal surface coming first with the
membranes trailing after tt. It occasionally, however, escapes
edgewise.

Abnormalities In the Mechanism of the Third Stage of
Labor.— Retention of tlie placenta occurs verj' frequently. As
the placenta is fully separated, the lit-niorrhage is slight. The

MECHANISM OF THE THIKD STAGE OF LABOR.

397

placenta simply lies in the dilated lower uterine segment and the
upper portion of the vagina.

The treatment consists of the proper application of Crede's
method of expression. Sometimes the placenta lies across the

OS uteri in such a manner that atmospheric pressure determines
its retention. In such cases a finger may be hooked over one
edge to pull it down.

Adhesion ol the placenta to the uterine wall occurs about once

Fig. 261,— The exjjulti

in 312 cases. The adhesion is rarely complete ; a part of the
placenta is usually detached. This condition of affairs neces-
sarily gives rise to profuse hemorrhage. The placental sinuses
are torn when the placenta is detached, but the womb can not

398 THE MECHANISM OF LABOR.

contract and close tliem. because of the attached area and in
consequence of the retention of the whole placental mass within
the uterus (see Fig. 262).

Diagnosis. — Crede's method of expression fails completely to
express the placenta ; the womb will not firmly contract, and
there is alarming hemorrhage.

Treatment. — The hand should be inserted along the cord as

F!k. iSz, — PaKial detathmenl of the ptoccnU. Vertical mesial leclion rrom a
caM of eclampsia, delivered in arlinih mortis by forcepi: a, I'lacpnti still attached ;
t, placeata separated frotn ils site and hanging free; i, membranes; d, blood 1
t, membranes (Simii).

a guide to the placenta. A detached edge should be sought,
under which the fingers arc inserted, and tlie separation is com-
pleted with the finger-tips, moving them from side to side. Oc-
casionally it will be necessary to pinch through a dense spot of
adhesion with the nails of the thumb and forefinger. The pla-
centa being separated, the fingers should be closed about it.

MECHANISM OF THE THIRD STAGE OF LABOR.

399

The fundus should be stimulated by friction through the abdom-
inal wall, and the uterine contractions should be allowed to
expel the hand and the contained placenta. It is unwise to pull
the placenta out, even when it is completely detached, for the
combined mass of the placenta and hand may act like the piston
of a syringe and draw the uterus inside out.

Prognosis. — Many women die from heniorrhSge ; about seven
per cetit. lose tlieir lives from sepsis. Most exceptionally the

Fig, 26j, — Melhod of

placenta is retained in utcro for months without doing harm,*
The rarest anomalies in the mechanism of the third stage of
labor are hernia of the placenta through the muscular coat ol

' Wallace, " Indian Medical Record," abstract in Tendon *' Ijincet," iSgl,
ports Ibe Tclenlion in uliro of an almost full lenn placenta for [wo monlhs wilhout
intonvenience lo the mother. Loisne! ('■ Nour. Arch, d' Obslel,." May, 1891, sup-
pleiD.) reported 1. case in which the fetal head, after decapitation, was left in the
uterus for three months without symptoms of sepsis, Heirgou, in the discuani
this report, slated that he bad »een the placenta retatoed n-ilhin the Dtenis for seven
months al^er childbiith.

400

THE MECHANISM OF LABOR.

the uterus and prolapse of the normally situated placenta. The
latter is most likely to happen with twins, after rupture of the
uterus, or in premature labor, but it has been observed at term,
without injury to the uterus, and in a single pregnancy. There
is not necessarily profuse hemorrhage nor other disadvantage to
the woman, but the fetus dies unless it is extracted at once.'

' *' Prolapsus Placenta;," Ingcislev, " Centralbl. f. Gyn.," No. 40, p. 94I, 1893 ;
" Zur Kasuislik des Prolapsus Placentie hei normalem Sili derselben," Hid., No. 5,
1393. "Hernia of ihe placenia through the muscular coal of the uterus during
labor," J, G. I.ynds, •■ Med. News," 1^3, p. 77.

PART IV.
THE PATHOLOGY OF LABOR.

CHAPTER I.

ANOMALIES IN THE FORCES OF LABOR.

In a normal labor the active forces of expulsion (the uterine
and abdominal muscles) and the passive forces of resistance (the
fetus, the pelvis, and the maternal soft structures) are so nicely
balanced that the expulsive forces are just sufficiently resisted to
insure a slow and gradual passage of the fetus along the birth-
canal. The walls of the birth-canal and the structures around
the vulvar orifice are by this arrangement slowly and gradually
dilated, and are not rudely torn apart, as they would be by a
more rapid expulsion of the fetus. This balance between the
powers of labor, however, is easily disturbed. There may be
anomalies by deficiency and anomalies by excess in the com-
ponent parts of the forces of expulsion and in all the sources of
resistance. Thus, the uterine muscle may be too weak or too
strong compared with the resistance it must overcome ; and so
also with the action of the abdominal muscles. The resistance
furnished by the pelvis, the soft structures, and the fetus may be
excessive or deficient.

I. Deficient Power of the Uterine Muscle; Inertia Uteri.
— In this condition the uterine muscle is unable to overcome the
normal resistance offered by the weight of the fetal body, by the
friction of the pelvic walls, and by that of the undilated maternal
soft structures. Inertia uteri is manifested, in the vast majority
of cases, during the first stage of labor. The weakened uterine
force, therefore, is almost always neutralized by the obstruction
of an undilated cervix. There is scarcely another condition in
obstetric practice that can be traced to such a variety of causes
or that demands so many different plans of treatment.

Etiology. — Deficient power of the uterine muscle in labor
26 401

402 THE PA THOLOG Y OF LABOR.

may be due to a defect of the muscle itself, to some anomaly of
innervation, or to a mechanical interference with the full and
effective action of the muscle. Examples of the first-named
cause may be found in imperfect development of the uterus or in
anomalies of development, as in uterus bicomis. The uterine
muscle may be exhausted by rapidly succeeding pregnancies.
It may be overdistended by twins or by hydramnios, thus losing
the power gained by cohesion of muscular bundles. The uterus
may be weakened by some cause — as an adynamic fever or a
wasting disease — that weakens the whole organism, but it does
not necessarily follow that uterine weakness always accompanies
a reduction of body-strength. Women in the last stages of
phthisis or in the midst of an attack of typhoid fever or pneu-
monia occasionally exhibit a uterine power in labor above the
normal. The uterus may be weakened by profuse hemorrhage,
as in placenta praevia. It may be rendered incapable of exerting
normal force in dry labors. The liquor amnii having drained off
completely early in the first stage, the uterus retracts upon the
child's body, thus being subjected in certain regions to severe
and long-continued pressure, and becoming in those spots anemic
and friable, while in the areas free from the pressure of the child's
body the uterine wall becomes congested, swollen, and edematous.
Above all, the uterine muscle may become fatigued. This is the
commonest cause of uterine inertia. It is seen oftenest in primip-
arae, in whom inertia is more than twice as common as in mul-
tiparae, on account of the difficulty of dilating the rigid cervical
tissues. Inertia may appear in consequence of any serious
obstruction in labor. At first the pains are feeble, infrequent,
and inefficient, but as labor continues the uterine contractions
gather force. The inertia from this cause is likely to be only
temporary, seen at intervals between periods of stormy uterine
action or of long-continued tonic spasms, until finally ex-
haustion of the whole organism threatens the patient's life or the
uterus ruptures.

It has been asserted that an anomaly of innervation in the
anatomical sense, a deficient supply of the terminal nerves in the
individual muscle-cells, is a cause of uterine inertia, but it is not
yet clearly demonstrated to be so. An inhibitory nervous im-
pulse to the uterine muscle, on the contrary, is a frequent cau.se
of uterine inaction. It is the result of some emotion or of
great pain. That the "doctor has frightened the pains away '*
on his first arrival has become proverbial in the lying-in room.
The presence of an\^ one who is a cause of embarrassment or is
disagreeable to the patient may have the same effect. In hyper-
esthetic women the uterine contractions may be so exquisitely

ANOMALIES IN THE FORCES OF LABOR, 403

painful that their first onset is followed by an inhibitory impulse
which cuts them short almost immediately. Every clinical
observer has seen the phenomenon of rapidly recurring, very
painful uterine contractions, which are, however, of short dura-
tion, and which secure no appreciable dilatation of the cervical
canal. A woman may be tortured thus for hours in the early
part of the first stage of labor, when this inhibitory nervous im-
pulse is commonly observed. With the continuance of labor the
individual becomes more or less indifferent to her surroundings
or more inured to suffering, and the inhibitory nerves, probably
derived from the spinal cord, apparently lose the power of
responding to the stimulus of pain.

Among the mechanical causes of inefficient uterine action
during labor are fibroid tumors of the uterine walls, displace-
ments of the uterus, old peritoneal adhesions, and fresh out-
breaks of periuterine inflammation.

Diagnosis. — ^Thc recognition of uterine inertia should always
be easy. The contractions of the muscle are of short duration
and are separated usually by long intervals, and by palpation the
observer may convince himself that they are feeble. The uterus
during the pain does not assume that intensely hard consistency
which normal vigorous action of the muscle in labor occasions.
The patient's expression, action, and demeanor point to deficient
force during the pains. The woman is more placid, the face is
less contorted, and there is less outcry during the contractions
than in the normal parturient patient, except in those cases in
which excessive pain inhibits uterine action. In these cases,
however, abdominal palpation and the short duration of the pains
are sufficiently plain signs of the inertia. Finally, labor is de-
layed. During the first stage dilatation is slow or does not
progress at all, and in the second stage the presenting part does
not advance. One fatal error in the diagnosis of inertia uteri
should be avoided : the physician should be sure that labor
is not delayed by some obstruction. It has happened in a
careless and sup)erficial examination that the observer has taken
the distended and thinned lower uterine segment for an inert
uterus. In such a case the measures adopted to stimulate the
supposedly inactive uterine muscle to overcome an obstacle that
is insuperable might easily be interrupted by rupture of the
uterus. A methodical and careful examination will guard one
against this error. The source of obstruction will be discovered.
The firmly, perhaps tetanically, contracted upper uterine segment
may be contrasted with the inactive lower segment by palpation
of the whole anterior surface of the uterus. The contraction -ring
should be visible, and the whole uterus stands out with unusual

404 THE PA THOL OG Y OF LABOR,

prominence, from the anteversion that always accompanies pro-
longed and powerful uterine contraction.

Treatment, — From the diversity in the causes of inertia uteri
it follows that no single plan of treatment can be depended upon.
If uterine action is inhibited by emotion, the cause of nervous
disturbance should, if possible, be removed. An objectionable
person should leave the room. If excessive pain prevents
effective contractions, an analgesic should be administered.
Nothing is better for this purpose than chloral administered in
15-grain (0.97 gm.) doses, repeated, if necessary, twice at inter-
vals of fifteen minutes. A quarter of a grain (0.0162 gm.) of
morphin hypodermatically comes next in order of efficiency. If
the uterine muscle is simply apathetic, it can be aroused by some
direct irritant. The insertion of a bougie as for the induction
of labor answers the purpose well. A more effective but more
troublesome measure is the dilatation of the cervical canal by
Barnes* bags, which not only irritate the uterine muscle, and
thus bring on strong contractions, but also artificially dilate the
cervical canal, and thus relieve the uterine muscle of a great part
of its task in the first stage of labor. If the head should be
well engaged in the pelvis, however, the insertion of the bags is
difficult, and they are likely to cause malpositions of the head.
In such cases, if the os is dilated to the size of a silver dollar,
nothing is so effective as the application of forceps, — not to
drag the head through the undilated cervical canal, but to
pull it at intervals firmly down upon the cervix. The impact
of the head upon the cervix acts as a powerful reflex irritant,
and will excite as strong contractions as any direct irritant can
do. Not only so, but the pull of the head upon the cervix
will gradually dilate the canal as effectually as could strong
propulsion from above. As soon as effective pains are estab-
lished and the dilatation of the cervical canal progresses satisfac-
torily, the forceps should be removed.

Inertia uteri so profound as to demand the somewhat radical
measures just described is, fortunately, rare. More commonly
the physician sees the minor grades, in which there is simply a
flagging of uterine effort during the first stage, especially in
primiparai, accompanied by every evidence of temporary physical
and mental exhaustion. After a jDeriod of rest effective contrac-
tions reappear, even if nothing wliatevcr is done to aid the
patient. The more complete the rest, the more vigorous is
the uterine action wlicn it is resumed, and for this reason the
administration of chloral and opium is often followed, afl;er a
time, by a satisfactory- progress in labor. But these drugs neces-
sarily retard the termination of labor by the time of rest they

ANOMALIES IN THE FORCES OF LABOR, 40S

secure. It is ordinarily desirable, therefore, to resort to drugs
of a stimulant character that shall at once revive the flagging
uterus and so hasten the delivery. Many medicaments have
been recommended for this purpose, but, of them all, alcohol,
quinin, and ergot alone deserve consideration. The last was
employed extensively at one time, but clinical experience forbids
its use to-day. The contractions of the uterus induced by ergot
are likely to become tetanic. The uninterrupted contractions
interfere with the fetal circulation ; they may cause fatal intra-
uterine asphyxia, and they often produce such exaggerated
blood-pressure and stagnation of the current in the fetal body
as to induce extravasations in important viscera, especially the
brain. Further, the circular fibers of the cervix come under the
influence of the drug, and by their firm contraction neutralize
the contraction of the longitudinal fibers of the uterine body,
and thus retard labor almost indefinitely ; and, worst of all,
should there be some obstruction to the descent of the child in
the maternal pelvis or in the fetal body, the administration of
ergot predisposes to rupture of the uterus. For these sufficient
reasons this drug, as a stimulant to the uterine muscle in the first
and second stages of labor, should be banished from the obstetri-
cian's pharmacopeia, except in the single instance of the birth of
the second of twins. Owing to the recommendations of Albert
H. Smith and of Fordyce Barker, quinin has had, and still has,
a great reputation as a stimulant to the uterus in labor. My
experience with the drug, however, does not permit me to sub-
scribe unreservedly to a belief in its efficacy as a uterine stimu-
lant in labor. Quinin has the positive disadvantage, moreover,
that in certaiA susceptible individuals it will, occasionally, produce
a violent postpartum hemorrhage. In the minor grade of inertia
under description, so often seen in primiparae, and almost always
the result of exhaustion, the writer has found nothing so useful
as alcohol, in the shape of a wineglassful of sherry, taken slowly
with a biscuit, and given with the positive assurance that it will
bring back the pains and hasten the conclusion of labor, for the
patient often needs moral and mental support as much as she re-
quires a physical and muscular stimulus.

An impression prevails among general physicians that inertia
uteri in the first stage of labor, before rupture of the membranes,
may safely be disregarded. In a measure this view is correct.
There is often a partial dilatation of the os and then an entire
cessation of uterine contractions for many hours and even for
days. I have seen one case in which the cervical canal was
sufficiently dilated to receive four fingers, and it remained so
for more than a week, the patient all the while going about on

406 THE PA THOL OGY OF LABOR.

her feet in perfect comfort, without a single painful contraction
of the uterus. But should inefficient uterine contractions be
accompanied by much pain, as happens in some cases of inertia,
the long-continued first stage should not be regarded with indif-
ference. The patient will in time show the irritant and depress-
ant effects of long-continued suffering in an elevated temperature,
an accelerated pulse, and a lessened resisting power of body-cells,
the last playing an important role in the predisposition to sepsis
after labor. Another consequence of delayed, painful labor may
be seen in sensitive, nervous individuals who are at first thrown
into a state of excitement and then from gloomy forebodings of
harm to themselves and to their infants, pass into an almost
maniacal condition of terror and dread.

It should be a rule of practice, therefore, to watch carefully
all cases of inertia uteri, and to interfere as soon as the patient's
mental condition or her pulse, temperature, and general vigor
are demonstrably affected by the delay in labor.

2. Excessive Power in the Expulsive Forces of Labor. — An
actual excess of power in the expulsive forces in labor suffi-
ciently great to expel the fetus precipitately is extremely rare.
A relative excess is not uncommon. The child's body may
be so small, the pelvis so abnormally large, the maternal soft
parts so relaxed, that the ordinary power exerted by the uterine
and abdominal muscles is far in excess of that required to over-
come the weak resistance offered, and the child is fairly shot out
of the birth-canal. The rapid delivery may cause serious re-
sults to both mother and child. In the woman the structures
of the pelvic floor may be lacerated severely ; the sudden evac-
uation of the uterus predisposes to hemorrhage from inertia ;
the placenta may be detached prematurely ; and the sudden
evacuation of the abdominal cavity predisposes to dangerous
syncope. For the child the chief danger is the possibility
of unexpected delivery of the mother in the erect posture. The
umbilical cord may rupture, and the child, falling to the ground,
may be fatally injured. Precipitate and unexpected labors occur
most frequently when women are seated upon the water-closet.
The child is evacuated into the waste-pipe or down a well and
may be destroyed. Some astonishing examples of infantile
vitality, however, arc furnished by such cases.

Unfortunately, the physician is usually not at hand to pre-
vent a precipitate delivery and to avert its consequences. Should
he find an infant descending the birth-canal with a rapidity
dangerous to itself and to its mother, he can easily retard its
progress by pressure with his hand against tb'^ ^^ itiqg
part

ANOMALIES IN THE FORCES OF LABOR. 407

3« Excess in the Resistant Forces in Labor. — !• Deformities
of tlie Peivls. — Comprehensive and satisfactory knowledge of
deformities in the female pelvis has been gained only in
the latter half of the present century, since the appearance
of Michaelis* work in 185 1.^ Until the announcement by
Arantius in the last quarter of the sixteenth century that a
contracted pelvis is a serious obstacle in labor, the prevailing
belief had been that difficult labors from mechanical ob-
struction by the maternal bones were due to a failure on the
part of the pelvis to expand sufficiently for the passage of the
child. This idea continued in force for a number of years after
Arantius* time. According to Litzmann, Heinrich von Deventer
(165 1 to 1724) should be regarded as the real founder of our
knowledge of the pelvis and its anomalies. He described the
inclination of the pelvis, the axis of the pelvic inlet, the con-
tracted pelvis, and the flat pelvis. Pierre Dionis was the first
to point out ( 1 7 1 8) the relationship betweefi rachitis in childhood
and a deformed pelvis in the adult. William Smellie's con-
tributions to the study of the female pelvis were remarkably full
and clear, when one considers how little was known before his
time. His description of the rachitic pelvis, his reflections on
its cause, and his accounts of illustrative cases may be read with
profit to-day. Roderer, Stern, Cooper, Vaughan, Denman,
Baudelocque, and Fremery added much to the stock of knowl-
edge during the latter half of the eighteenth century. The men
of the present century to whom we owe most of our present
information about the pelvis and pelvimetry are Naegele, Kilian,
Rokitansky, Michaelis, Robert Litzmann, Neugebauer, and many
others to whom reference will be made in the sections devoted
to the particular varieties of deformed pelvis. ^

Frequency of Deformed Pelves. — It is difficult to estimate the
frequency in America of pelves sufficiently deformed to influence
decidedly the course of labor. Statistics from our lying-in
hospitals afford little aid to a correct conclusion, because the
inmates are chiefly European immigrants and negresses. In
the Boston Lying-in Hospital, however, deformed pelves were
found in two per cent, of native -bom and in six per cent, of
foreign-bom women (Reynolds).^ My experience in private
and consulting practice convinces me that deformed pelves
are by no means rare among native-bom women in the densely
populated centers of the Eastem States. No general practi-

" "' Das eoge Becken."

•* Drei Voitrilgc Uber die Geschichte von der Lehre dcr Geburt bei
Hs ** Geburt bei engem Becken," etc., 1884.

r. Gyn. Soc.," 1890, p. 367.

408 THE PATHOLOGY OF LABOR.

doner, in a targe city at least, can hope to avoid such cases,
and it is hkely that each year will afford him one or more
striking examples. It follows that an ability to recognize deform-
ities of the female pelvis is a necessary accomplishment for every
practitioner of medicine who may be called upon to attend
women in confinement, and that a knowledge of pelvimetry is as
essential to the intelligent and successful practice of obstetrics
as are percussion and auscultation to the practice of medicine.
European statistics bearing on the frequency of contracted pelves
give the following results : Michaelis found in looo parturient
women 131 contracted pelves ; Litzmann, 149, Winckel found
in Rostock 5 per cent., in Dresden 2.8 per cent., and in Munich
9.5 per cent, of contracted pelves among pregnant and parturient
women. Winckel believes that 10 to 15 per cent, of child-
bearing women have contracted pelves, but that in only 5 per
cent, is the obstruction serious enough to be noticed. Kalten-
bach puts the frequency of contracted pelvis at 14 to 20 per
cent. In Marburg it was found to be 20.3 per cent, in Gottin-
gen 22 per cent., in Prague 16 per cent. Schauta estimates it
at 20 per cent.

Classification of Anomalies In Uie Female Pelvis. — All classifica-
tions are merely a convenience for the teacher and student It
is rarely possible to draw sharply defined lines between varying
manifestations of a condition. The majority of German authors
follow Litzmann's classification of abnormalities of the female
pelvis, by which they are broadly divided into those of size and
those of shape. Modem French authors adopt the still less
satisfactory division of oversize, undersize, and anomalies of
inclination. Schauta's classification is, in my opinion, the most
convenient, and I have utilized it, with a slight modification.^

Simple flat pelvis.

Generally equally contracted pelvis ( justo-minor).
Generally contracted flat pelvis (non-rachitic).
Narrow funnel-shaped, fetal, or undevelojied pelvis.
Imperfect development of one sat:r;il al.i ( Naegelc pelvis).
Imperfect development of both sacral ala; (Robert pelvis).
Generally equally enlarged pelvis { justo-majorj.
Split pelvis.

' Mliller-s " H-

tt it

ti it

ANOMALIES IN THE FORCES OF LABOR. 409

ANOMAUES DUE TO DISEASE OF THE PELVIC BONES.

Rachitis.

Osteomalacia.

New growths.

Fractures.

Atrophy, caries, and necrosis.

ANOMALIES IN THE CONJUNCTIONS OF THE PELVIC BONES.

Abnormally firm union (synostosis), which is found in elderly
primiparae, particularly at the sacrococcygeal joint and
in the joints between the coccygeal bones :
Synostosis of the symphysis.

one or both sacro-iliac synchondroses,
the sacrum with the coccyx.
Abnormally loose union or separation of the joints :
Relaxation and rupture.
Luxation of the coccyx.

ANOMALIES DUE TO DISEASE OF THE SUPERIMPOSED SKELETON.

Spondylolisthesis.

Kyphosis.

Scoliosis.

Kyphoscoliosis.

Lordosis.

ANOMALIES DUE TO DISEASE OF SUBJACENT SKELETON.

Coxalgia.

Luxation of one femur.

Luxation of both femora.

Unilateral or bilateral club-foot.

Absence or bowing of one or of both lower extremities.

Diagnosis of Pelvic Anomalies ; Pelvimetry. — Deformities of the
female pelvis may be detected by the history of the patient, by
her appearance, by palpation of the exterior and interior of the
pelvis, and by external and internal measurements of those
pelvic diameters that are accessible, or of salient points on the
W0OEian'8 body corresponding as nearly as possible with the
peBranements desired, the relations between the two
itiaoertaiiied by many observations on dead and
y pelvic measurements the examiner's
modified mathematician's calipers
in)loyed. Baudelocque (1775)
•ar in ordinary use. He laid

THE PATHOLOGV OF LABOR.

Fig. 264. — Osiander's pel'

Pig. 265. — Modem combinstton
of Baudelocque's and Osuider'i pel-

ANOMALIES IN THE FORCES OF LABOR.

411

the foundations of pelvimetry, and his instrument and methods
are in use at the present time (Figs. 265—268). It is con-
venient to describe the measurements of the diameters of the
pelvic inlet, pelvic cavity, and pelvic outlet separately.

Measurement of the Anteroposterior Diatneter of tlu Superior
Strait. — This measurement, the most important in the pelvis,
can not be taken directly. It must be estimated by several

plans. Haudtlocquc was the first to point out the relation be-
tween the niea.surement from the depression under the last
spinous process of the lumbar vertebra; to the upper edge of the
symphysis pubis, and the true conjugate diameter of the pelvic
inlet. To this external measurement the name " e.x'temal conju-
gate " was given, but it is often called " the diameter of Uaude-
locque" (Fig. 268). Its discoverer believed the relation

4 1 2 THE PA THOL OGY OF LABOR,

between the external and internal diameters to be constant, —
that the one exceeded the other by 8 to 8^ centimeters, — ^but
in this he was mistaken. The line of the external diameter
does not usually coincide with the line of the internal, and the
thickness of bones and superimposed structures differs, of course,
in each individual. In thirty cases in which Litzmann had an
opportunity to compare the measurement of the external conju-
gate taken during life with the actual measurement of the true
conjugate taken after death, there was an average difference of
9.5 centimeters, but the maximum difference was 12.5 centi-
meters and the minimum 7 centimeters, — a variation of 5.5
centimeters in a small number of cases. Michaelis found a
difference of 0.6 to 3.2 centimeters and Schroeder i^ to 3
centimeters between the external conjugate of the living body
and that of the dried specimen. The measurement of the exter-
nal conjugate, therefore, is not to be relied upon in making an
estimate of the size of the true conjugate. It simply serves to
indicate the probability or the improbability of pelvic contrac-
tion. An external conjugate of 16 centimeters or under means
certainly an anteroposteriorly contracted pelvis ; between 16
and 19 centimeters the pelvic inlet will be contracted in more
than half the cases ; between 19 and 21.5 centimeters there will
be but ten per cent, of contracted pelves ; and above 21.5 centi-
meters it is almost certain that the conjugate diameter of the
pelvic inlet is not contracted at all. The external conjugate
can not be measured accurately without some practice. The
beginner in pelvimetry will do well to remember the following
rules :

Have the patient dressed for bed. Place her upon her side,
with t;he thighs slightly flexed and the clothing rolled well up
out of the way, the lower part of the body being covered with
a sheet. The examiner stands at the patient's back, facing her
head. The depression below the last spinous process of the
lumbar veitebras is found by rubbing a finger-tip ov^er the lumbar
spines from above downward until the finger sinks into the de-
pression sought and feels no more prominent spinous processes
below. * The knob at the end of one branch of the pelvimeter
is placed firmly in this depression and is held there with one
hand, while the finc^ers of the other hand find a point on the
symphysis pubis about ^s of an inch below its upper edge,
on which point the other branch of the pelvimeter is firmly
set ; the pelvimeter having been so ]:)laccd that the indicator is
turned toward the examiner, the measurement is therefore easily

^ Michaelis preferred the measurement from the tip of the last lumbar spinous
process, instead of from the depression below it.

ANOMALIES IN THE FORCES OF LABOR,

413

read off as soon as the pelvimeter is in proper position. It \s
on the average, in well-built women, 20^ centimeters.

The best measurements for determining the length of the
anteroposterior diameter of the pelvic inlet are those taken from
the lower edge of the symphysis pubis to the promontory of the
sacrum, — the diagonal conjugate diameter, — and the distance
between the upper outer surface of the symphysis pubis and the
promontory of the sacrum. The diagonal conjugate diameter
is one side of a triangle, the other two sides of which are the
height of the symphysis and the true conjugate. The distance
between the outer upper surface of the symphysis and the pro-
montory of the sacrum differs from the true conjugate by the
thickness of the upper portion of the symphysis. Smellie was
accustomed to estimate roughly the length of the true conjugate
by a digital examination, basing his estimate on the ease with

Fig. 269. — Stcin*s instrument for direct measurement of the conjugate.

which the promontory could be reached. In the latter part of
the eighteenth century Johnson ^ proposed, for estimating the
size of thie pelvic inlet, a method which consisted of inserting the
fingers of one hand in the mouth of the womb and then spreading
them between the promontory and the sacrum. A few years
later the elder Stein devised a graduated rod for measuring the
distance between the lower edge of the symphysis pubis and the
division between the second and third sacral vertebrae. This dist-
tance he believed to be one-half to one inch greater than the true
conjugate. Stein later constructed the instrument for the direct
measurement of the conjugate shown in figure 269. Many
instruments have since been constructed on this principle, but
they are impracticable in the living female, for obvious reasons.
Baudelocque was the first to propose the measurement of the
diagonal conjugate and the subtraction from it of an average

1769.

* Robert Wallace Johnson, ** A New System of Midwifery," etc., London,

414

THE PATHOLOGY OF LABOR.

figure (j^ of an inch) to dctennine the length of the true con-
jugate. His method, exactly as he described it, is still in use,
with the exception that two fingers instead of one are employed
in measuring the distance between the symphysis and the pro-
montory. To measure the diagonal conjugate correctly, the
examiner must have the skill that comes of practice, and he
must conduct his examination in a careful and methodical man-
ner. The patient is put in the lithotomy position and is brought
to the edge of the table or bed on which she lies, so that the
buttocks project well over it. The examiner cleanses his left
hand and anoints the
first tivo fingers with an
unguent; he then inserts
these fingers, held stiffly
extended, inward and
upward, until the tip of
the second finger finds
and rests upon the pro-
montory of the sacrum.
Care must be exercised
not to take the last lum-
bar for the first sacral
vertebra or vice versa,
nor the second for the
first sacral vertebra, —
mistakes easily made
in cases of so-called
" double promontory."
With tlie tip of the sec-
1 md finger resting firmly
in place upon the mid-
dle Hue of the promon-
tory, the radial side of
the hand is elevated
until the impress of the arcuate ligament under the lower edge
of the symphysis is plainly felt upon it With a finger-nail of
the other hand a mark is made upon this point of the examining
hand, which is then withdrawn (Fig. 270). The distance between
this mark and the tip of the middle finger held extended is taken
by a pelvimeter. This distance is the diagonal conjugate. By
the observation of many subjects, alive and dead, an agreement
has been reached that i ^ centimeters should be subtracted from
the diagonal conjugate to obtain the true conjugate diameter.
But the acceptance of this average difference depends upon a
normal height of the symphysis, 4 centimeters ; a nortnal angle 1

ANOMALIES IN THE FORCES OF LABOR. 41 5

between the axis of the pubis and the true conjugate, 105°; a
normal thickness of the symphysis, and a normal height of the
promontory (Figs. 271 to 275). These factors, however, are
not constant, and if they vary much from the normal, the most
skilful and most experienced obstetrician may be misled woefully
in his estimation of the true conjugate. 1 have had under
my care a rachitic dwarf in whom there was more than 3 cen-
timeters' difference between the diagonal and true conjugates,
and Pershing found, among ninety pelves in the museums of
Philadelphia, a difference varying from 0.8 centimeter to 3.6
centimeters. It is declared that these sources of error may be
eliminated by the following corrections : For every d^ree of

increase in the conjugatosymphyseal angle add half the number
of millimeters to the sum to be subtracted from the diagonal
conjugate, and vice versa ; also, for every 0.5 centimeter increase
in the height of the symphysis over the normal add 0.3 centi-
meter to the sum to be subtracted from the diagonal conjugate,
and vice versa. While these rules are admirable for the study
of the dried specimen in a museum, they are not easily applied
to the living pregnant female. The height of the symphysis
can be measured in the living subject, but an allowance for
variations in this respect eliminates error in only a small propor-
tion of cases. The variations in the angle of the symphysis, a
much more important source of error, can only be surmised.
la caaea upon the border-line between the relative and absolute

4l6 THE PATHOLOGY OF LABOR.

indications for Cesarean section in which the difference of a
centimeter would decide one for or against the operation I

prefer the measurement between the upper outer edge of the
symphysis pubis and the promontory of the sacrum for the

ANOMALIES IX THE FORCES OF LABOR. 4I7

Fig. 275, — EITecl of the leasEned slant outwatd of the <iynipli^sis in a rachitic
pelTis upon the relilionshlp between the liue and the coajugale diameter ( Ribemonl-

Deoaignes).

4i8

THE PATHOLOGY OF LABOR,

estimation of the true conjugate, having demonstrated its supe-
rior accuracy in practice. For taking this measurement the
patient is put in the dorsal posture, with the buttocks projecting
beyond the edge of the table or bed pn which she lies. A mark
with the point of a lead-pencil is made on the skin over the
symphysis pubis, about ^ of an inch below the upper edge.
The two fingers of the left hand are inserted in the vagina, as
in measuring the diagonal conjugate. The tip of the middle
finger, having found the middle line of the promontory, is
moved a little to the patient's right, and tip b of the pelvimeter,
shown in figure 278, is made to take its place. While the
examining physician holds the shaft of the pelvimeter firmly in

Fig. 276. — Author's pelvimeter; a^ For measuring the true conjugate plus the
thickness of the sympliysis ; ^, with extra tip added for measuring the thickness of
the symphysis.

place, an assistant adjusts tip a of the movable bar over the
mark made on the symphysis. This bar is then screwed tight,
the whole pelvimeter is removed, and the distance between the
tips is found by a tape-measure. This distance is the con-
jugate plus the thickness of the symphysis (Fig. 279). The
latter I have found to be i centimeter \\\ twenty -six dried pelves,
I y^ centimeters in nine, i l< centimeters in thirteen, I y^ centi-
meters in four, and 2 centimeters in three specimens — one a
high-grade rachitic pelvis, another of the masculine type, and
the third a justomajor pelvis. The thickness of the symphysis
is measured as shown in fi^j^ure 278. In living subjects the index-
finger of the left hand must find the inner surface of the symphy-
sis pubis, and must follow it up to within about ^ of an inch

ANOMALIES IN THE FORCES OF LABOR.

419

of the top, where it bulges to its full thickness. On this point
one tip of the pelvimeter is placed, and it is then held in position
between the ends of the first and second fingers ; the other tip
of the instrument is adjusted over the mark made on the skin

Fig. 177. — Meaburinglhe

of Ihe Bylnphysi^i, with the

Fig. 37S.— -Meaauring ih« Ihickncu ai the sympbysis, wilh Ihe author's peUimcteT.

externally ; the distance is read off from the indicator provided
for the purpose. It is not necessary to make an allowance for

the thickness of the tissues over the symphysis, for this is
included in both measurements, and on subtracting one from
the other the necessary correction is made. The tissues over

420 THE PA THOL OG Y OF LABOR,

the inner ' surface of the symphysis can usually be so com-
pressed by the knob of the pelvimeter as to be practically elimi-
nated. If this is impossible, as may happen in some primiparae,
a small allowance may be made for these tissues — say, at the
most, 0.5 centimeter. In measuring a pelvis by this method it
may be necessary to anesthetize the patient ; and this is well
worth while if a decision between some of the more serious ob-
stetrical operations is to be based, as it must be, upon an accur-
ate estimation of the true conjugate.^

Measurement of the Transverse Diameter of the Superior
Strait. — ^The transverse diameter of the pelvic inlet can not be
measured directly, nor can it be estimated accurately. Fortu-
nately, it is not necessary to do it. It is sufficient to deter-
mine whether there is a decided diminution of the measurement,
without determining the exact degree of lateral contraction.
To do this the following measurements are relied upon : The
distance between the anterior superior spinous processes of
the iliac bones, which in well-formed women is 26 centimeters ;
the distance between the crests of the iliac bones, 29 centi-
meters ; the distance between the trochanters, 3 1 centimeters ; the
distance between the posterior sujjerior spinous processes of the
iliac bones, 9.8 centimeters ; the distance between the subpubic
ligament and the upper anterior angle of the great sacrosciatic
notch, which, according to Lohlein, is 2 centimeters less than
the transverse diameter of the inlet ; finally, an estimation of the
width of the pelvic inlet by a vaginal examination. In taking
the external measurements the woman is placed upon her back.
The salient points are easily found except in the case of the iliac
crests. They are discovered by moving the knobs of the pel-
vimeter evenly along the crests of the ilia until the two opposite
points most widely separated from each other are found. If the
crests are no further, or even less, separated from each other
than the spines, points five centimeters back of the latter are arbi-
trarily selected as the sites of the crests. The posterior sujjerior
spinous processes are often marked by distinct dimples on the
woman's back. The internal measurement of Lohlein is made
by the fingers in the vagina. If all these measurements are
much less than normal, a lateral contraction of the pelvis may
be assumed, and the degree of contraction is roughly estimated
by the amount of decrease in the measurements, although the
relation between these measurements and the distance sought is

1 Wellenbergh was the first tr •-•«**»» thia iwId*'**'** *

pelvimeter was improved upc*
by Bullitt (" Deutsche m^"
1893; MUlIer's*'Haiid]

ANOMALIES IN THE FORCES OF LABOR,

421

'^.r-^^

Fig. 279. — Skutsch's method of measuring the conjugate diameter.

['s method of measuring the transverse diameter of the
pelvic inlet.

422 THE PA THOLOG Y OF LABOR.

very variable. The efforts of Skutsch and of others before him,
accurately to measure the transverse diameter of the pelvic inlet
by combined internal and external measurements, have not yet
been crowned by success. The softness of the tissues exter-
nally permits the external knob of the pelvimeter to sink into
the flesh to a varying degree, and the same is true of the struc-
tures within the pelvis. It is difficult also to keep the pelvimeter
in the same straight line when the internal knob is changed
from one side to the other (Figs. 279 and 280). Moreover, better
results in practice may be obtained by an estimate formed by a
vaginal and a combined examination, under anesthesia if neces-
sary, of the relative size of the transverse diameter of the pelvic
inlet and the anteroposterior diameter of the child's head.

Measurement of the oblique diameters of the pelvic inlet is
required only in obliquely contracted pelves. It will be referred
to in the description of these pelves.

The Measurement of the Capacity of the Pelvic Cavity. — The
capacity of the pelvic cavity must be estimated by vaginal ex-
amination. There is no plan by which accurate measurements
can be made. It is sufficient to estimate the size and the shape
of the pelvic canal by palpating the lateral walls of the pelvis ;
by determining the curve, perpendicularly and laterally, of the
sacrum ; by noting the height of the sacrosciatic notches, the
approximation of the tuberosities of the ischia, the depth of the

pelvis, and the direction of its

^^-"^ll^v canal ; by detecting, possibly, the

^W ^B/ . presence of an exostosis, an osteo-

[0 j^^l[J sarcoma, an abnormally project-

W^^^^ iiig spinous process, an old frac-

wW^ ture, or asymmetry of the pelvic

[ m walls from any cause.

\\ \ AIeasure?ne?U of the Transverse

Diameter of the Pelvic Outlet. — The
anteroposterior diameter of the in-
ferior strait is enlarged during labor
by the displacement backward of
the coccyx. The transverse diam-
Fig 281. -Measurement of the ^^^^ between the tuberosities of

anteroposterior diameter of the pel- ..... ,

vie outlet. the ischiatic bones is constant, and

if there is contraction of the outlet
the greatest resistance to the escape of the fetus is furnished by
these firm bony eminences. The transverse diameter of the pelvic
outlet can be measured directly with ease. The woman is placed
in the dorsal posture, with thighs and legs flexed. The distance
between the tuberosities of the ischia is '"^ -^ with a pel-

ANOMALIES IN THE FORCES OF LABOR.

423

vimeter, or the examining physician places his thumbs squarely
on the tuberosities, and an assistant measures the distance be-
tween the physician's thumb-nails.

If it should be desired to measure ihc antaopostcrior diam-
eter of the pchic outlet, this may be done as is shown in figure
283. 1.5 centimeters being subtracted for the thickness of bone
and superimposed structures. Or, the extended first and second
finger of the left hand may measure the distance from the lower
edge of the symphysis pubis to the tip of tlie sacrimi,

4. Description of the Several Varieties of Abnormalities
in the Female Pelvis. — ^The simple fiat pelvis (Fig. 282) is the
earliest recognized form of contracted pelvis — the pehis plana
of Deventer, who did not, however, make a distinction between
the simple flat and the rachitic fiat pelvis. It is doubtful, indeed,
if he knew the difference
between the two. Betschler
*vas the first to point out the
distinctive features of this form
of pelvis. In Europe it is the
commonest variety of de-
formed pelvis. Schroder states
that it is seen more frequently
than ail tile other forms put
together. In America it is
also common, but the equally
generally contracted pelvis is
encountered here as often or
perhaps oftener. Out of a
series of 316 pelves in women
of American birth. I have
found eighteen (a percentage
of 5-6) with the measurements characteristic to s
simple flat pelvis.

Cttaracteristics. — In the simple flat pelvis the sacrum is small
and is pressed downward and forward between the iliac bones,
but is not rotated forward on its transverse axis. The antero-
posterior diameter is contracted, therefore, throughout the whole
of the pelvic canal. The contraction, however, is not often
great It is scarcely ever below 8 and is usually not under
9.5 centimeters.*

■ TTie abbrevialions. r. v., tr., and M., >vi11 Iw used throughoul [o designnLe [he
true conjugate, the transverse, and oblique diameleis of ihe pelvic inlet.

* Kngelken has deicribed a specimen with a true canjugnle of 4,8 cenlimclEn,
> diagonal conjugate of 7.5 cenlinielcrs, with transveree and obliriue diameleis of the
inlet 13,3 and 12.4 ceniimeiers respectively. This apeeimen ia

Fig. 2S2

—Simple

fini pel

8 Men..; .r.

'iH cm

; ohi..

(m«iel in a

Ihor's CO

of Penn>ylv.i

niu).

2 degree of a

424 THE PA THOLOG Y OF LABOR.

The transverse diameter is as great as, or possibly greater
than, that of the normal pelvis. Occasionally, however, in pelves
approaching the type of the generally contracted flat pelvis the
transverse diameter may be found somewhat diminished. There
is in these pelves quite frequently a double promontory formed
by the abnormal projection of the cartilaginous junction between
the first and second sacral vertebrae. The line drawn between
the lower promontory, or the second sacral vertebra, and the
symphysis is often as small as, or smaller than, the true con-
jugate.^

Etiology, — The simple flat pelvis has been ascribed to heredity,
to an arrested rachitis, to overwork before puberty (especially
the carrying of heavy weights), to premature attempts to walk
or to sit up, and to the weight of a heavy trunk upon a pelvis
ill fitted to bear it on account of weakness of its ligaments. It
is probable that in the majority of these pelves the form is
inherited and congenital. It has been found by Fehling in a
number of fetuses and new-born infants.

Diagnosis, — The simple flat pelvis is easily overlooked.
There is nothing in the patient's appearance or history to sug-
gest the deformity, unless she has had difficulty in previous
labors. The characteristic signs are the diminished anteropos-
terior diameter, determined by internal and external measure-
ments, and a transverse diameter as great as, or greater than,
normal, or perhaps a trifle under the normal measurement. This
last point is determined by measurements externally and by the
internal palpation of the pelvic canal. In measuring the conju-
gate diameter of the flat pelvis one must take into account the
lessened inclination of the symphysis outward, its height, some-
what below the normal, and the low position of the promon-
tory. Usually the average sum of i V^ centimeters is a sufficient
amount to subtract from the diagonal conjugate. If there is a
double promontory, as is frequently the case in this form of
pelvis, the conjugate must be measured from the promontory
nearest to the symphysis, usually the lower (Fig. 283).

hifluence Upon Labor, — From the failure of the presenting
part to enter the pelvis during the last weeks of gestation there
is frequently some degree of pendulous abdomen, especially in
women with abdominal walls relaxed from previous pregnancies.
The uterus is sometimes broader than common, and is often
tilted to one side. The presentini^ part, if the head, may be loose

^ Crcd6 found, in nine pelves with a double promontory, the conjugate from the
true promontory longer in four and shorter in three cases than the conjugate measured
from the false promontory. In two cases the two conjugates were of equal length
{*• Klin. VortrSge iiber Geburtshulfc," Berlin, 1853).

ANOMALIES /A" THE FORCES OF LABOR.

above the superior strait, resting on one iliac bone or on the
symphysis, or it may be pressed down firmly upon the brim in a
transverse position, to accommodate its longest diameter to the
longest diameter of the pelvic inlet. Malpresentatioiis are com-
mon, as is also prolapse of the cord and of the extremities.
The membranes may protrude in a cylindrical pouch from the
external os as the liquor amrni is forced out of the uterus without
obstruction from the imperfectly engaged head. From the same
cause an early rupture of the membranes is likely. According
to Litzmann, natural forces end the labor in seventy-nine per
cent of cases, but in fifty per cent, the head is not fully engaged

^1 until the os is completely dilated. The dilatation of the os pro-

B^ ceeds slowly, for the ht;ad does not descend low enough to press

H upon the cervix. Consequently the dilatation must be effected

B by a retraction of the cervix over the head or by the distended

V membranes. Should the latter rupture, the os. although consider-

^ft ably dilated, may retract until the head at length descends and

^B again dilates it. After the obstruction at the superior strait is

' passed, — where, of course, it is greatest, — the head usually de-

scends the remainder of the birth-canal with ease and rapidity,
but labor may be prolonged by an exhaustion of the natural forces
tempt to secure engagement. The apparent anomalies in

e promonloiy ;

426 THE PA THOLOG Y OF LABOR.

the mechanism of labor characteristic of this deformed pelvis are
in reality the best possible provision for the spontaneous obviation
of the obstruction. The transverse position of the head at the
inlet, the increased lateral inclination, and the imperfect flexion
are designed to accommodate the size and the shape of the head
to the unnatural size and shape of the pelvic inlet. An explana-
tion of these peculiarities in the engagement of the head may be
found in the altered relation of expulsive and resistant forces.
The head, forced down upon the flattened brim and free to move
upon the neck, rotates until its longest diameter is adjusted to
the greatest diameter of the inlet — the transverse. It seeks the
direction of least resistance, as any inert body will when prof)elled
through a contracted canal. But the transverse position of the
head alone is not sufficient to overcome the obstruction. The
biparietal diameter of the head is too large to enter the conjugate
of the pelvis. The occiput, the bulkiest portion of the skull,
seeks the greater space to one side of the promontory, and is
pushed against the lateral brim of the pelvis — the iliopectineal
line. Here it is arrested. Further propulsion of the head is
secured by a movement of partial extension, which brings the
small bitemporal instead of the larger biparietal diameter of the
head in relation with the contracted conjugate. Still, the obstruc-
tion may not be overcome. Both sides of the head may be
unable to enter the pelvis at once. One side is propelled into
the pelvic canal, the other is held back. That side which
encounters the most resistance will naturally be the last to enter.
Thus it is that usually the anterior parietal bone, slipping more
easily past the symphysis, enters first. To this result also the
inclination of the pelvic axis to the axis of the trunk contributes.
Owing to the anterior position of the whole sacrum and to the
diminished anteroposterior diameter of the pelvic outlet ; on
account, also, of the transverse position of the head and of its
imperfect flexion, rotation of the head on the floor of the pelvis
occurs late, and occasionally fails altogether, the head being
expelled from the vulva in its original transverse or in an oblique
position.

The localized pressure to which the maternal structures are
subjected results sometimes in necrosis of cervical tissue over the
promontory and of the anterior vaginal wall behind the sym-
physis. On the child's head the caput succedaneum is not
exaggerated, because the head, when once firmly engaged in the
pelvis, descends the birtli-canal rapidly, but there is apt to be a
depression on that portion of the skull applied to the promontory
— namely, on the posterior parietal bone between the greater
fontanel and the parietal eminence, usually quite close to the

ANOMALIES IN THE FORCES OF LABOR.

427

sagittal suture (Fig. 284). Sonietimes a succession of tliese
depressions or a gutter-shaped groove may be noted in a line
running outward and forward on the child's skull. More fre-
quently the course of the head and face over tlie promontory is
marked by a red streak running from the depression before noted
in a line parallel with the coronal suture toward the temple if tlie
head is well flexed after engagement, or to the outer comer of the
posterior eye, or, in case of extreme flexion, to the cheek (Fig.
28s, A, B, C). Usually the posterior parietal bone is depressed
below the anterior, wiiicli overlaps it at the sagittal suture. The
posterior side of the skull is also flattened from the greater and
more prolonged pressure to which it is subjected. Ordinarily

the lateral inclination of the child's head is in a direction from
before backward, so that the anterior parietal bone presents at the
center of the superior strait. Occasionally this inclination is so
c^gB^rated that the ear is the presenting part. Exceptionally
the lateral inclination takes the opposite direction, the anterior
parietal bone catches on the rim of the pubic bones, and the
posterior parietal bone is the first portion nf the child's head to
enter the pelvis. The presentation of the posterior fontanel
occurs even in normal pelves as a rare exception, but is .seen in
about tun per cent, of contracted pelves (Schauta), and is the
result in them very likely of firm abdominal walls and an
increased inclination of the pelvic inlet to the axis of the trunk.

4Z8 THE PATHOLOGY OF LABOR.

In these cases the anterior parietal bone is pushed under the
posterior at the sagittal suture. When the posterior side of the
head by descent finds room in the hollow of the sacrum and
moves backward, the anterior portion of the skull glides over
the symphysis and the sagittal suture moves from its original
position, just behind the symphysis, toward the median line of
the pelvic canal. In addition to these anomalies of mechanism
Breisky describes what he calls an " e\tramedian " engagement
of the head in cases of flat pelvis in which there is considerable

lordosis of the lumbar vertebra-. The head in extreme flexion
is forced down upon half of the pelvic inlet, and enters the pelvic
canal on this side alone. Directly the obstructing promontory
and lumbar vertebra are passed the head descends the pelvic
canal with rapidity and ease. This mechanism was noted nine-
teen times in Breisky's clinic among 2002 labors.'

1 " Die liecken Anomalien," by Friedrich Schauta, in MUI1er'» " Hsndbacli der
Gcbaitshflire." Bd. il : Belschler, " Annal' n dcr klinischen AnMalten," i. pp. 24, 60;
ii, p. 31 : Engellien. " Dis.-Tn»ug.." MUnchen. 1878: " Ziir Kenlniss der eitrt-
median Einstellimg des Kopf»," Kobn. " Frager Zeilschnfl f. Hdlkunde." Bd. ix.

ANOMALIES IN TME FORCES OF LABOR.

429

Justomtnor Pelvto. — In this type of contracted pelvis the
form of the female pelvis is preserved, but the size is diminished.
Three divisions of this pelvis are commonly made : 1\\g juvenile,
in which the bones are small and slender ; the iHasciUinc, in
which the bones are large, heavy, and thick ; and the dwarf, or
pelvis nana, in which the pelvis is very diminutive in size and
the pelvic bones are not joined by bony union, but are separated
by cartilage as in the infant. The innominate bones are divided
into their three parts, and the sacral vertebrae are distinct from
one another. The jiistominor pelves pass by insensible grada-
tions into the simple flat, the transversely contracted, and the
generally contracted flat pelves. In the larger cities of the United
States the justominor pelvis is very frequently encountered. ]t
is certainly as common here as is the simple flat pelvis, and if
one were to judge from hospital patients, among whom there is
a large proportion of shop- and factory girls, this variety of
contracted pelvis would be regarded as tlie commonest.

Cluiracteristics. — While it is convenient to speak of the justo-
minor pelvis as the normal female pelvis in miniature, the de-
scription is not strictly accurate. There are peculiarities due to
an arrest of development which give to the equally generally
contracted pelvis some of the features of an infantile pelvis.
The alse of the sacrum are narrower than they should be in
comparison with the bodies of the vertebra. The sacrum is
short and is not pushed as far forward between the iliac bones
as it usually is ; it shows also a diminished forward inclination,
and on its anterior surface a greater lateral and a less marked
perpendicular concavity than common. The di.stance between
the posterior superior spinous processes of the iliac bones is
relati\'ely great, on account of tlie posterior position of the
sacrum and its slight rotation forward. The conjugatosym-
physeal angle is greater than normal, by reason of the' lessened
inclination outward of the symphysis and the pubic bones. The
promontory is high and not prominent, and the inclination of
the pelvic entrance to the abdominal axis as the individual stands
erect makes a more obtuse angle than it does in the normal
pelvis. The bones in this form of contracted pelvis are com-
monly small and slender. e.\cept in the rare masculine pelvis,
in which they are firm and thick beyond the normal. \Vomen
with a justominor pelvis are ordinarily of slight build and below
the medium height ; but this pelvis may be found in individuals
of ordinary stature, and sometimes actually in tali women with a
large frame.

The true dwarf pelvis is very rare. It is found only in
women of dwarf stature. The bones are slender and fragile.

430

THE rATllOLOGY OF LABOR.

and the cartilaginous junction between the original divisions of
the pelvic bones is preserved. There is extreme contraction of
the pelvic canal.

In the commoner kinds of justorainor pelvis the contraction
is not often very great. The conjugate diameter is seldom below
nine and scarcely ever as low as eight centimeters. The pelvic
outlet in some cases is laterally contracted ; in others it is com-
paratively roomy.

Etiology. — The justominor pelvis is the result of arrested
development ; it may be found in women descended from a stock
that has deteriorated phys-
ically, or in women sub-
jected during childhood,
infancy, or intra-uterine
existence to unfavorable
hygienic surroundings or
conditions.

Diagnosis. — The jus-
tominor pelvis is easily
confused with a rachitic
pelvis, but the di.stinction
is readily made by careful
pelvimetry. All tlie meas-
urements, while equally
reduced, bear their normal
proportion to one another,
except in the case of the
external conjugate diam-
eter, which is apt to be
longer than would be ex-
pected, on account of the
posterior position of the
sacrum and its lessened
inclination forward. In
estimating the true conjugate diameter from the diagonal conju-
gate one must often take account of the increase in the conju-
gatosymphyseal angle, and must remember that the sum to be
subtracted from the diagonal conjugate is not infrequently greater
than common. The symphysis is less in height than in the
normal pelvis, but the error of computation from this source may
be disregarded. Lohlein lays special stress upon the importance
of measuring the pelvic circumference in making the diagnosis
of this form of contracted pelvis. It is always far below the
normal, ninety centimeters. An internal examination of the pelvic
cavity and inlet should be made carefully, to determine approxi-

4N0MAI.IES I.V THE FORCES OF LABOR.

431

mately their capacity, with a special regard lo the approximate
length of the transverse diameters.

Influence on Labor. — The mechanism of labor shows far
fewer anomalies in this than in any of the other forms of con-
tracted pelvis. The head, from the greater resistance encoun-
tered, is strongly flexed. It may be placed transversely, but is
quite commonly oblique, and may even be anteroposterior in
position if then; is a tendency to lateral contraction of the pelvic
canal. By the perfect flexion of the head the obstruction to the
progress of labor is in great part obviated. If anything inter-
feres with this movement of the head, as a faulty application of
the forceps, engagement and descent may become impossible.
Pelvic presentations in labor are a great disadvantage by reason
of the difficulty experienced in freeing the arms and in bringing
the head last through the generally contracted pelvic canal.
To secure its rapid passage,
the child's head must be
flexed stronglj' by the oper-
ator's finger in its mouth
before an attempt is made
to secure engagement in
tiie superior strait. While
the woman escapes local-
ized necroses of the soft
tissues following labor in
the justominor pelvis, there
is greater likelihood of
rupturing pelvic Joints in
this than in any other
variety of contracted pel-
vis, and there is also an
extraordinary liability to
eclampsia (Fig. 287). The caput succedaneum, which is very
large on account of the early fixation of the head and the long
labor, is situated directly over the smaller fontanel. There is
an overlapping of the cranial bones, both laterally and antero-
posteriorly.

The generally contracted, flat, non-rachitic pelvis presents the
combined features of the flat and the generally contracted pelvis.

Characteristics. — All the diameters are below normal, but
the conjugate is less in proportion ihan any of the others. This
pelvis has many of the features of a rachitic pelvis, but the
anterior half of tlie pelvic circumference is not markedly broad-
ened ; indeed, it is often the reverse. The sacrum is small and
is not rotated on its transverse axis ; it is placed further back

■s »i>pl;a

I. {author's collection).

43 2 THE PA THOLOG Y OF LABOR,

between the innominate bones than in the normal pelvis, and
very much further back than in the rachitic pelvis. The pro-
montory is high and is not prominent. The influence of this
deformity of the pelvis upon labor is that of a flat pelvis, but the
difficulties are greater than in the case of the simple flat pelvis,
for there is less compensatory room in a transverse direction.
The generally contracted, non-rachitic, flat pelvis is comparatively
rare. The flattening, according to Litzmann, is due to a short-
ening of the innominate bones, especially at the iliopectineal
line. In estimating the true conjugate diameter of the generally
contracted flat pelvis it is safer to subtract 2 instead of i ^ cen-
timeters from the diagonal conjugate, on account of an increase
in the conjugatosymphyseal angle, the result of the high posi-
tion of the promontory and the diminished slant outward of the
symphysis.

Etiology, — ^The generally contracted flat pelvis is due to
hereditary influence or to an arrest of development in the embryo,
fetus, or infant. It is claimed, however, that it may be produced
by premature attempts to walk and by long standing upon the
feet in very early life.

Diagnosis. — The recognition of a generally contracted flat
pelvis is difficult. The measurements usually resemble those of
a generally equally contracted pelvis, but the conjugate diameter
is less than one expects in that form of contracted pelvis, and
the mechanism of labor is that of a flat pelvis. The diagnosis
can be made by finding the reduced conjugate diameter and by
the ease with which one can reach the lateral pelvic wall in the
palpation of the interior of the pelvic canal. A certainty of diag-
nosis can be obtained during life only by the direct measurement
not only of the conjugate diameter, but also of the transverse,
by the methods of Lohlein and of Skutsch.

The Narrow, Funnel-shaped Pelvis ; Fetal or Undeveloped Pelvis.
— This variety of pelvis is contracted transversely at the pelvic
outlet, or both in the transverse and anteroposterior diameters,
without abnormalities in the spinal column. The depth of the
pelvic canal is much increased by the length of the sacrum, of the
symphysis, and of the lateral pelvic walls. The sacrum is narrow,
has little perpendicular curve, and is placed far back between the
ilia (Fig. 288). Schauta ascribes this form of contraction to an
anomaly of development by which the pelvic walls are length-
ened downward and the weight of the body is thrown backward
upon the sacrum. It is said to be very rare, but it has been
found quite frequently in those hospitals where the outlet of the
pelvis is regularly measured. It comprises from five to nine per
cent of all contracted pelves, according: to Breisky, and Fleisch-

AKOMALIES IN THE FORCES OF LABOK-

433

Fig. l88.— Narroi

, fun n el-shaped pel-
(r. (miet), S!^ cm.;
[HMl. outlel, 7Ji cm.
r'a colleclion).

mann found twenty-four examples in 2700 parturient women, •
A slight manifestation of the deformity is often called a " mascu-
line " pelvis, by reason of the diminution in the breadth of the
pubic arch. This degree
of the funnel-shaped pelvis
is frequently encountered
(Fig. 289).

Diagnosis. — The diag-
nosis of a narrow, funnel-
shaped pelvis is made by a
comparison of the measure-
ments of the pelvic inlet
with those of the outlet
The former are found to be
normal or even greater than
normal, while tlie measure-
ments of the outlet are di-
minished. If, as is the rule 'r*((,uilel)',7°cm.*:'anl.
in extreme degrees of this (specimen in tlie auiho
deformity, the inlet and
cavity are contracted, Uie outlet is still smaller in proportion. A
careful palpation of the pelvic canal is an important aid to a
correct diagnosis. The pelvic walls are felt to convei^e as they
approach the outlet ; the narrowness of the pelvic arch is appre-
ciated, and the approxima-
tion of the tuberosities and
spines of the ischiatic bones
is noticeable.

Influence upon Labor. —
The peculiarities of mech-
anism in labor arc malpo-
sitions of the head at the
outlet (as backward rota-
tion of the occiput), oblique
and transverse position of
the head, and imperfect
flexion. There is also an
insufficiency of the expul-
sive forces, the greater part
of the fetal body being con-
tained in the lower uterine
segment, cervix, and vagina, while the upper muscular segment
of the uterus is in great part emptied and therefore powerless.

" Prager Zeilschrift f Heilkundc," B

and 5.

434

THE PArnOLOGY OF LABOR.

By the approximation of the pubic rami the presenting part is
forced backward, and serious lacerations of the perineum are
to be feared. The pressure of the head upon the lower birth-
canal may result in necrosis of soft structures or in lacerations
along the descending rami of the pubis and the ascending
branches of the ischium. The tissues over the projecting
spines of the ischiatic bones are also the seat of tears or of
necroses. The narrowing of the pubic arch may lead to serious
injuries if the forceps be applied. I have seen long, clean
cuts in the anterior vaginal walls and profuse hemorrhage fol-
lowing the use of instruments. In well-marked examples of
the narrow, funnel-shaped pelvis, \\ith a transverse diameter at
the outlet not much below three inches, symphysiotomy gives
the best chance of a successful termination for motlier and child.
Higher grades of contraction witli a diameter of two inches and
under demand Cesarean section. In lesser grades the woman
may be delivered spontaneously or by forceps.

Obliquely Contracted Pelvis from Imperfect Development of the
Ala on One Side of the Sacrum {Nacgcie Pehi's). — This peh is was
first described in 1834 by Franz Carl Naegcle,' but had been
noticed as early as 1779
without a full understand-
ing of its significance (Fig.
290).

Cliarartfristics. — Th.e
pelvic inlet has an oval
shape, with the small point
of the oval directed to
the atrophied side of the
sacrum. The sacral ala is
atrophied or is absent not
only in that portion of the
bone entering tiie sacro-
iliac joint, but also in the
Fig. 290.— Jjl)li.|ii. I; i.i.r .1..I i" :m- transverse process along

its whole length. The
sacro-itiac joint on this side is ankylosed in the vast majority of.
cases, but not invariably. The sacrum is narrow, asymmetrical,
and turned with its anterior face toward the deformed side of the
pelvis. The promontory is not only turned in this direction, but Is
also pulled over to the diseased side. The innominate bone on the

' "Die Heidelberger klinischen AniinUii," BJ. x. p. 4<
descHbcd in his folio nlias, "Das SchrBg verengle Deciien,
e wichtigsten Fcblerdel WcibI, Beckeoa Ueberhuupl,"

■laboratclj'

ANOMALIES IN THE FORCES OF LABOR. 43 5

deformed side is pushed as a whole upward, backward, and inward,
and its anterior face is pushed inward and backward. The tuber-
osity of the ischium, as a necessary consequence of the displace-
ment of the innominate bone, is higher than its fellow, projects
further into the pelvic canal, and is so turned that it looks rather
anteroposteriorly than laterally. The spine of the ischium is
brought quite close to the corresponding edge of the sacral bone
and juts prominently forward into the pelvic canal. The whole in-
nominate bone on the diseased side lacks its normal curvature at
the iliopectineal line, and may run almost straight from the sacro-
iliac junction to the symphysis pubis. The opposite innominate
bone has a greater curvature than common, especially in its
anterior half; otherwise it is practically normal in structure,
position, and inclination. The symphysis pubis is pushed toward
the healthy side of the pelvis, and its outer surface, instead of
looking directly forward, is inclined to the diseased side. The
pubic arch likewise faces somewhat in this direction ; its aperture
is asymmetrical and irregularly contracted, as the ischiac and
pubic rami on the diseased side are pushed inward upon the
pelvic canal and over toward the healthy side (Fig. 290).

Etiology. — The cause of the obliquely contracted pelvis under
description is an absence of the bony nuclei in the ala or lateral
process on one side of the sacrum. The lateral process conse-
quently fails to develop, and the innominate bone is brought in re-
lation with the bodies of the sacral vertebrae. As a result, there
must be some distortion of the innominate bone even in fetal and
infantile life, but this is increased to an exaggerated degree when
the individual begins to walk. Instead of receiving the pressure
from the lower extremity approximately on the keystone of an
arch, as does a normally curved innominate bone, the deformed
bone in a Naegele pelvis transmits the pressure in almost a
straight line upward and backward, so that the extremity of the
posterior arm of the arch slides past the sacro-iliac joint instead
of resting firmly on it as an arch does on its abutments. The
irritation and strain of this unnatural movement bring about in
time the atrophy and ankylosis of the joint.

That the deformity in this kind of oblique pelvis does not
follow a primary ankylosis of the sacro-iliac joint is proven by
the fact that the innominate bone is pushed backward and
upward on the sacrum — a movement that would be impossible
were this joint first ankylosed. As a further proof of primary
lack of development and secondary ankylosis, there is no trace
of inflammation in or about the ankylosed joint, and the alae or
transveise processes of the sacrum are atrophied or are absent
along the whole length of the sacrum, and not only in that

43^ THE PATHOLOGY OF LABOR.

portion of it which enters into the composition of the sacro-iliac
joint.

Diagnosis. — The recognition of an obliquely contracted
pelvis from arrested development of the sacral alse may be very
difficult. There is nothing to direct the attention of the phy-
sician to the possibility of the deformity. There is no history of
previous disease or of accident, no scar of an old tistula over the
joint, and the patient does not limp. The diagnosis can be
made only by a methodical external and internal palpation of the
pelvis and by careful measurements. If the outspread hands are
laid over the innominate bones, it will be noticed that the dorsal
surfaces arc directed obliquely forward and backward as they lie
upon the diseased and healthy sides. An internal palpation of
the pelvis will detect one lateral wall much nearer the median
line than the other, and the diagonal conjugate will be found to
run not anteropostcriorly in direction, but from before backward
and from the healthy to the diseased side of the pelvis. There
are a number of points from which measurements may be taken
that will show inequalities where in the normal pelvis the dis-
tances should be the same or should difler by a very small sum.
Naegele recommended the following measurements: (i) The
distance of the tuber ischii on one side from the posterior
superior spinous process of the ilium on the other ; (2) from the
anterior superior spinous process of one ilium to the posterior
superior spinous process of the other ; (3) from the spinous
process of the lart lumbar vertebra to the anterior superior
spines of both ilia ; (4) from the trochanter major of one side to
the posterior superior spinous process of the opposite iliac bone ;
(S) from the lower edge of the symphysis pubis to the posterior
superior spinous processes of the iliac bones. In addition to
these measurements, others of value have been suggested by
Michaelis and by Ritgen. These are the distances from the
middle line of the spinal column to the posterior superior spinous
proces.ses of the iliac bones, and the distance from the lower edge
of the symphysis to the ischiac spines, and from these spines to
the nearest point on the edges of the sacrum. In this latter
measurement it will be found that the distance from the symphy-
sis to the ischiac spine is longe.st on the diseased and shortest on
the healthy side, while the distance from the ischiac spine to the
edge of the sacrum is very much shorter on the diseased thari
on the healthy side. The last, whicii is a vcr>' important meas-
urement, can easily be taki_'ii |iv Luini; fin uter-breadt lis bctw
the points to be measured.

[nflumce on /^afajaW-Tlie mechanism .if l^or itt an obliqticly
contracted pelvis

ANOMALIES IN THE FORCES OF LABOR.

437

contracted pelvis. The shape of the pelvic entrance and canal
is symmetrically ovoid, and the head can enter the contracted
space only by extreme flexion. Th^ are none of those anoma-
lies of position, flexion, and inclination of the head which are
seen in the flat pelvis. As the head descends, the birth-canal
anomalies of mechanism may appear resembling those described
in the narrow, funnel -shaped pelvis — namely, abnormal and
imperfect rotation and anomalies of flexion. Depending upon
the degree of deformity, there is more or less interference with
the progress of labor to complete obstruction. The head is
almost invariably found entering the pelvis and passing through
the canal with its longest diameter in coincidence with the
longest oblique diameter of the pelvis, from the diseased sacro-
iliac joint to the opposite iliopectineal eminence.

Prognosis. — In the recorded cases the results of labor in the
Naegele pel\-is have been bad. Of 28 women reported by IJtz-
mann, 22 died in their first labor, 5 of them undelivered. Three
of these women died in consequence of their second labor, and
2 after the sixth. Out of 41 cases, 6 were delivered spontane-
ously, 12 by the forceps, 14 by craniotomy, 5 by version and
extraction. 4 by premature labor, and 2 by Cesarean section.
The following accidents were noted in the course of labor or
shortly afterward : Rupture of the uterus or vagina, vesico-
vaginal fistula, fracture of the horizontal ramus of the pubis,
rupture of the sacro-iliac joint and of the symphysis. In
another scries of cases, 28 women furnished forty-two labors
with tlie following results: 2\ died as the result of the first
labor, 3 of the second, and i after the sixth. These women
were delivered seven times by craniotomy, once by Cesarean
section, four times by premature labor, and in a number of
instances by forceps. Outof4i children in Litzmann's statistics,
there were only 10 delivered alive, 2 of these by Cesarean section
and 2 by premature labor. The 6 other living children were all
bom of the same mother. ^

Treatiiiciit. — Forceps and version are not. as a rule, success-
ful in the treatment of labor obstructed by an obliquely con-
tracted pelvis unless the degree of deformity is slight. The
induction of premature labor and the performance of Cesarean
section are the most successful means of delivery, but the former
should be resorted to only when the distance between the lower
edge of the symphysis pubis and the sacro-iliac joint of the
..healthy side is not under 8.5 centimeters. In twenty forceps
ts thirteen women died. The proposition of Pinard to

wriur is indebled for lhe»e si

9 Schauta {Inc.

■I.).

438 THE PATHOLOGY OF LABOR.

do what he calls ischiopubiotomy has not met with favor. The
room gained by the movement outward of the innominate bone
on the healthy side, the other being, of course, immovable, will
be sufficient only in pelves so slightly contracted as to allow a
delivery by much simpler means.

Transversely Contracted Pelvis the Result of Imperfect Develop-
ment of Both Sacral Ala. — This pelvis was first described in 1842
by Robert, and is generally known as the " Robert pelvis "
(Figs. 291 and 292), It is the rarest of all contracted pelves.
Schauta was able to find but six examples recorded in child-
bearing women. Ferruta has recently reported another case.'
Herman gives eight as the number of recorded cases. The
anatomical conditions are the same as in tiic Nacgelc pelvis,

^mij,

Kig. 291. — TraQsvcfatl} CdiiltJCltd
pelvis, showing contrnclion at outlet
[model in author's collection).

Fig. 29a. — Transversely contiacird
pelvis: C.V., 9V cm.; tr. (oulleO. 5
cm.; IT. (inlet), 8 cm. (mnHel in MQl-
ter Museum. College of Physiciios,
Pliilidelphin).

except that both sides of the sacrum are affected instead of one.
Other parts of the sacrum besides the ala:; may show imperfect
development. There is a case reported in which the whole
lower portion of the bone was absent The sacrum in the Robert's
pelvis is extremely narrow, and the posterior superior spinous
processes of the iliac bones are brought close together. The
degree of contraction in the transverse diameter is so extreme
that natural labor is out of the question. An asymmetry of the
Robert pelvis has been observed, one side showing a greater
degree of the deformitj' than the other, and thus approaching
the type of an obliquely contracted pelvis,

The causf of this deformity is an absence of the bony nuclei
in the sacral al;e of both sides. Secondarily, as in the Nacgel**

■ " Scudii dj Otiej^

ANOMALIES IN THE FORCES OF LABOR, 439

pelvis, there is usually an ankylosis of the sacro-iliac joints.
That this ankylosis is secondary and not primary is demonstrated
by the same condition which proves that ankylosis is not a
primary cause of the oblique contraction and ill -development of
^one side in the Naegele pelvis — namely, a displacement of the
ilia on the sacrum necessarily occurring before the ankylosis.

The treatment of labor obstructed by a transversely contracted
pelvis of this kind is Cesarean section.

Justomajor Pelvis. — A generally equally enlarged pelvis is
found in women of gigantic stature, but it may also be demon-
strated in a woman of medium height. The pelvis of the Nova
Scotian giantess was large enough to give passage to a child
weighing 28j^ pounds. The largest pelvis that has ever come
under my notice was found in a woman somewhat below the
average height, without an abnormally great development of
any other portion of her frame.

Diagnosis. — The diagnosis of a justomajor pelvis is made
mainly by external measurements. If all of them are found far
in excess of the normal while preserving their normal relative
proportion, the diagnosis of a justomajor pelvis is justifiable.
The internal examination, if considered necessary, will show that
the promontory is quite inaccessible, and that it is much more #
difficult than common to reach the lateral pelvic walls. This
anomaly of the pelvis does not, of course, obstruct labor ; on
the contrary, it predisposes to precipitate delivery, although the
resistance of the soft parts may be quite sufficient to delay the
process considerably, even though the pelvis present no obstacle
whatever. During pregnancy it is noted that the uterus has a
tendency to sink deep within the pelvic canal, so that pressure-
symptoms of the pelvic viscera and blood-vessels are common
in the latter weeks of gestation, and these symptoms may become
so exaggerated as to make locomotion difficult. In labor there
may be anomalies in the mechanism dependent upon insufficient
resistance to the engagement of the head. Thus imperfect flexion
at the superior strait may be observed, and there may be a
tardy rotation of the head on the pelvic floor.

Split Pelvis. — The split pelvis, which is due to a defect in the
development of the lower portion of the trunk in front, is almost
invariably associated with exstrophy of the bladder. This pelvis
has very rarely been observed in the child-bearing woman ; there
are on record but seven examples complicating labor. The
split pelvis presents no obstacle in parturition. There are
'*« same peculiarities in labor as in the justomajor pelvis —
a tendency to precipitate birth, and anomalies in the
1 the result of imperfect resistance. After labor it \s,

440 THE PATHOLOGY OF LABOR.

almost certain that there will be a prolapse of the uterus. The
diagnosis of this deformity pri;sents no difficulties, and no ob-
stetric treatment is called for in labor {Fig. 293).

The Kachitic Pelvis. — In the healthy life and growth of bones
two opposed processes are found : On the periphery there is an
active proliferation of cells to form the bone-structure, while in
the interior, bone -substance is being constantly absorbed by the
marrow. In rachitis the absorption of bone -substance [joes on
more rapidly than it does in healthy bone, and at the same time
there is in the periphery a very much more rapid proliferation of
cells, which do not. however, develop normal bone- structure.
Their growth and multiplication result in the formation of an
osteoid material deficient in lime-salts and much more pliable than
healthy bone. The result of this pathological process in the

Fig. agj.— Split pel.

— Typical tl>t richillc pelvi:
n.; cffec. tr.diatn,. II cm. (Mii
College of Ph)fsici«ns),

pelvic bones is to make the pelvis more sensitive than it should
be to the mechanical forces that are brought to bear upon it

In the rachitic pelvis the size and shape of the pelvic canal
are modified by three factors : the pressure from the trunk above
and the counlerpressure from the extremities below : the pull
on the pelvic bones by ligaments and muscles ; and an arrested
development

Characteristics. — The effect upon the shape and size of the
pelvic canal of rachitis in the pelvic boms i.s not uniform.
Several varieties of contracted |" 1 1 Tht com-

monest is the flat pelvis with sohj. lil the diam-

eters, but a most marked dimi.' ! i.TopnsIcrior

diameter (Kig. 294), Tlu 1 . ■■■ this

common form, a simple ll.i ' of

the transverse diameters, ;. Ititic

ANOMALIES IX THE FORCES OF LABOR.

441

pelvis (Fig. 295). and a so-called " pseudo-osteomaladc " pelvis,
in which the effect seen in osteomaiacia is produced by pressure
upon the bones softened by rachitis. There are other rare
forms of asymmetrical development, in connection usually with
spinal disease of rachitic origin, that will be described elsewhere.

Fig- 29S-— Gi

s coll cci ion).

Characteristics of the Flat, Generally Contracted Rachitic
Pelvis. — The sacrum is pressed forward and downward between
the iliac bone.s, and is rotated on its transverse axis, mainly by
the pressure of the trunk upon it, but partly by the pull down-

d of the psoas muscles upon the spinal column and the pull
>n the posterior surface of the sacrum by the erectores
es (Fig. 294). The effect of this movement would
to throw the tip of the sacrum and the coccyx

THE PATHOLOGY OF LABOR.

directly backward, so that the posterior surface of the sacral
bone would run an almost horizontal course as the woman stood
upon her feet. The attachments of the sacrosciatic ligaments
and muscles to the lower sacrum and coccyx, however, prevent
this backward movement of the bone as a whole, and, pulling
the lower portion of the bone forward, cause a sharp bend in it.
usually at the junction of the fourth and fifth sacral vertebne.
The sacrum is narrowed in its transverse diameter, and the
lateral concavity of the
antL'rior surface is eflaccd
by t!ie forward movement
of the bodies of the verte-
bra between the ala;. The
anterior surface of the sa-
crum, indeed, may be con-
vex from side to side. By
the pui! of the strong
sacro-iliac ligaments run-
ning from the sacrum to
the posterior superior spi-
nous processes of the iliac
bones the latter are pulled
downward and forward by
the descent of the sacral
promontory, and are con-
sequently made to ap-
proach one another behind,
but they do not keep pace
with the movements of the
sacrum, and consequently
project more prominently
than common on either
side. The natural result
of this movement forward
and inward on the part of
the posterior superior por-
tions of the ilia would be
to throw the anterior half
of the innominate bones outward, but this movement is opposed
by their junction at the symphysis, and to a less degree by the
attachment of Poupart's ligament to their anterior superior
spinous processes. The ilia, however, restrained by a somewhat
yielding force, are throwii to a certain degree outward and back-
ward, so that their upper edges run almost horizontally outward,
and the distance between tfacir anteriar apinea becomes little less

'ollPRe of Phyiioii

ANOMALIES IN THE FORCES OF LABOR, 443

than, the same as, or even greater than, the distance between
their crests. A further result of these combinec^ forces pulling
the innominate bones inward and forward behind and hold-
ing them in place in front is to produce. in them an abnormal
curvature, as in the case of the sacrum, or as in a bow bent
between one's hand and the ground (Fig. 298). The point of
angulation or greatest curvature is found on the ilio-pectineal
line, back of the median transverse line of the pelvic inlet,
near the sacro-iliac joints. On account of the flexion of the
innominate bones the transverse diameter of the rachitic pel-
vis is relatively increased, but, as the whole pelvis is com-
monly below the normal in size, this diameter rarely exceeds,
if, indeed, it equals, the normal transverse measurement. A
further consequence of the exaggerated curvature of the innom-
inate bones is to throw the acetabula forward, so that the

Fig. 298. — Schematic representation of the anterior position of the acetabula in
a rachitic pelvis. The pressure of the femora from before backward contributes to
the flattening of the pelvis (Schroeder).

counterpressure of the lower extremities is exerted more antero-
posteriorly than in the normal pelvis (Fig. 298). The pubic
rami and the symphysis are diminished in height and show a
lessened slant outward. The cartilage at the junction of the
symphysis projects inward upon the pelvic canal, standing out
above the level of the bones to such a degree that it is some-
times a source of injur}' to the head or to the maternal struct-
ures. The force of resistance at the symphysis to the outward
movement of the innominate bones sometimes bends the ends
of the pubic bones inward upon the pelvic canal, giving to the
pelvic inlet the shape of a figure 8. From the traction of the
adductor and rotator muscles of the thigh upon the tuberosities
of the ischiatic bones (increased in rachitis by the positions of the
acetabula and the bowing of the femora), the latter are pulled
outward and forward so that the pubic arch is greatly widened

444 ^■'''^' PATHOLOGY OF LABOR.

and the transverse diameter of the pelvic outlet is increased.
The anteroposterior diameter of the outlet is somewhat dimin-
ished by the excessive perpendicular curvature of the sacrum,
but the contraction is relatively much less tlian in the conjugate
of the inlet. The whole pelvis is tilted forward on its transverse
a-xis, so that the inclination of the superior strait is increased
and the external genitalia are displaced backward.

The bones of a rachitic pelvis are usually slighter and more
brittle than common. They may, perhaps, show no peculiarities
in structure, or in rare cases they may be found much thicker
and heavier than normal.

In the generally equally contracted rachitic pelvis — a rare
type — is seen mainly an arrest of development, the consequence
of rachitis in very early life, which retarded growth without
much affecting tiie shape of the pelvic inlet and canal, from the

Fig. 299. — Pseudo-

fact that the pelvis had not been subjected to the pressure of the

trunk during the active stage of the disea.sc, because it ran its
I course to complete recovery before the child attempted to sit up
" or to walk. Possibly, also, the disease in some of these cases is

not severe and lasts but a short time. As the deformity is the

result of arrested development, a transverse contraction is found

as in the fetal ill-developed pelvis.

The diagnosis of the rachitic origin ofthis type of pelvis is

made by the relations of iliac spines to crests, perhaps by the

history of rachitis in early infancy, and possibly by the signs of

the disease in other portions of the body.

In the pscudo-oslcomalacic pelvis (Fig. 299) the rachitis has

progressed to an extreme degree and has been long continued.

Efforts to walk have been made while the disc" •'e

ANOMALIES IN THE FORCES OF LABOR.

445

profjress, and possibly the weight of the trunk has been exag-
gerated by attempts to carry heavy burdens. As a consequence
of tiie pressure of the trunk and the counterpressure of the
lower extremities, the pelvis bends under the forces imposed
upon it. The sacrum sinks far down into the pelvic canal and is
sharply curved or bent from above downward ; the innominate
bones are bent at a sharp angle laterally, and the acetabula are
pressed inward upon the pel-
vic canal. When at length
the bone disease has run its
course, the pelvis is firmly
set, by the hardening of the
bones, in its unnatural posi-
tion and shape. The differ-
ential diagnosis between this
pelvis and the true osteo-
malacic pelvis is made by
the direction of the iliac
crests, by the firm constitu-
tion of the bones after the
disease has been arrested,
and by the signs of rachitis
in other portions of tiie
body. Osteomalacia, be-
sides, has certain peculiari-
ties of its own that enable
one to recognize it without
difficulty.

Diagnosis. — The diag-
nosis of a rachitic pelvis is
made by external and inter-
nal measurements, by pal-
pation of the exterior and
tincrior of the pelvis, by the
woman's history, and by her
appearance. An individual
who has had rachitis in
childhood is usually of small stature, with short, thick, curved
extremities ; a low. broad brow ; a large, square head ; a flat nose ;
a '• chicken breast," and enlarged joints. The lumbar lordosis and
the rotation of the sacrum produce a sway-back, most noticeable
when the woman lies on her back upon a hard surface. When she
stand.s erect the pregnant uterus near term falls abnormally for-
ward and downward, on account of the short abdomen and lack of
engagement of the presenting part (Fig. 300). The mostcliarac-

(Charpenlic

IS b«Uy or rachitis

446

TU£ r.lTlIOLOGVOf LABOK.

teristic facts in llcr history arc tliat slic vmlliol tnl 11 tlirct or tat
years of ajjc and was late in getting Iter te«h. By the pelvMt
the normal relation betw^cen the ihac spines and crests is bu«d
disturbed. The difttencc in distances bctweai tlie fomcr and
between the latter is much reduced The posterior supen"
spinous processes are approximated, and the depression iiiidcr
the last spinoUB process of the lumbar vertebia appmciesoru
actually in the line drawn between them. The cxlcm.l -.»•
posterior diameter of Ilaudelocque is b.-k.« Ihe nontial. Inlrr-

iMlly. tlK diagonal conjugate is found "™*7tldtove;
TtK- .s\tl>phx-sis has less of a slant outward '"»" " ''' ^ y^i
the immKmtorv is found low and prominent ; tne ^^^|^|,|y
»ltt.,Jy bent .ipon itself, and the pel™ '»"» .„ph,1.

i*.ll,.«. tin account of the inctea.sc in th=/7"f sOTph'*
«ll onsk- <l«e (o the lessened slant outward ol "" 'jL„,J
« )r*M t»x' centimeters should be subtracted 1""" '"f. ^t
«.^v««-. The dtireiY:nc-e between the two """I" " J j^,.
UKrr » »>< S" 'h>- Inw situ,ition of the promonloty. «i

> l« II certain e.vtcnt for the lessened slant 01 uk

ANOMALIES IN THE FORCES OF LABOR.

447

physis, but does not entirely neutralize it If a double promon-
tory is found, which in these pelvirs is not uncommon (Fig. 306),
the measurement should be taken from the promontory nearest
the symphysis. Occasionally the lordosis of the lumbar vertebrae,
the result of spinal rachitis, is so great as to constitute itSL'lfan
'.Ij.sirmirun abo\'e the pelvic inlet. In such a ca.^ic iho cfrt-ctive

conjugate must be tak-cn from a point above the sacrum to the
symphysis pubis.

infiuiHce on Labor. — Tlie influence of a flat rachitic pelvis on
labor is much the same as the influence of a simple flat pelvis,
except that the contraction, and consequently the obstruction to
labor, is greater in the rachitic form, and that the promontory of
the sacrum is more prominent and more sharply defined. The
anomalies of mechanism at the inlet are the same in both varie-
ties of pelvis, but they are exaggerated in the flat rachitic pelvis.
As soon as the obstruction at the inlet is overcome, the descent

THE PATHOLOGY OF LABOR.

I'iR- 30s — Flal laclulic pclvw
implknti^d by conKlgia. Cesarean sec-
in (seen in eonsulLation with Dr.
en, I, McKelway).

Fig. 306. — Rachi
«econd sac. tbiI. , 6 14
Philadelphia).

ANOMALIES IN THE FORCES OF LABOR.

450

THE PATHOLOGY OF LABOR.

of the head and its escape are more rapid in the rachitic pelvis,
because of the shallow canal and the expanded outlet. Injuries
to the child's head and to the maternal tissues from pressure are
common. In the former, a sharp indentation may be seen on that
portion of the skull pressed against the promontory in the efforts
to secure engagement, the so-called " spoon-shaped " depression,
with fracture of the parietal bone. Localized necroses are not
infrequently seen in the maternal structures, where they have been
nipped between the child's head and prominent portions of the
pelvic bones — namely, in the cervical tissues over the promon-
tory, or very rarely in the posterior vaginal vault, and in the
anterior vaginal wall behind the symphysis and the ridge of the
pubic bones. When the slough separates, openings may be
established between the birth-canal antl the peritoneal cavity,
the bowel, the bladder, and a ureter.

Osteomalsclc Pelvis. — Osteomalacia, a soft condition of the
bones in consequence of an osteomyelitis and an osteitis, is e.v-

ceedingly rare in America. There are certain parts of the world
where it is frequently seen, notably Italy, Germany, and Austria,
but in America there are but three or four examples on record.
The bones of the pelvis in this disease become so soft that they
yield to every force imposed upon them. They bend before the
pressure of the trunk from above, the extremities from below, and
the pull of the muscles attached to the pelvic bones. The flexi-
bility of the pelvis in extreme cases of osteomalacia may be appre-
ciated when it is stated that the superior iliac spines may be bent
backward until they touch the spinal column ; the horizontal
rami of the pubis may be pushed inward until they almost oblit-
erate the pelvic inlet ; and the tuberosities of the ischium may

ANOMAUBS IN THE FOfiCES 01- LABOR.

451

Fig. 31

be approximated until they nearly close the pelvic outlet Not
only are the pelvic walls so compressed that they almost oblit-
erate the pelvic canal, but the spinal column also, sinking under
the weight of tlie trunk, bends far forward and descends low into
the pelvis, occupying the little remaining room in the inlet and
canal, and becoming itself a serious obstruction to the engage-
ment of the presenting part. From the lateral pressure of the

W- thigh-bones the ischia and pubcs are pushed inward and back-

ward, making, by the former movement, a sharp, beak-like pro-
jection of tile pelvic inlet between the pubic rami, and by the
tatter much diminishing the size of the pelvic canal (Figs, 309,
310, and 311). The sacrum is rotated on its transverse axis and
is driven far down into the pelvic canal — an exaggeration of the
movement seen in a rachitic pelvis. The lower portion of the
sacrum and the coccyx are pulled far forward by the 1

Kg. 31 a.

452 THE PATHOLOGY OF LABOR. ^^^^^|

cles attached to them, so that the sacrum is bent at a sharp anisic ^^|

in its lower third.

The innominate bones are bent laterally at a ^H

point slightly anterior to the sacro-jliac junction, and the iliac ^^|

bones may be folded

upon themselves horizontally. The inclina- ^B

tion of the pelvis as a whole

^^^^^^^

ih much increased.

The diagnosis may be

^^F^

^^^^^^1

based upon the following

^^^^m

^^^^^^1

symptoms: The disease

^^^V

^^^^^^1

begins usually during preg-

^^^^1

^^^^^^^1

nancj- or lactation, with

^^^H

^^^^^H

dull aching pains in the

^^^B

^^^^^1

extremities, the back, the

^^^^^

^^^^^^k

lumbar region, and over

^:-

"^^^^^^^

the anterior portion of the

^^^^^H

pelvis. Every movement

^^^H

increases these pains, As

the disease progresses, the

bones of the spinal column

)

^ ■

are so bent and compressed

1 ■

that the indi\adual is dimin-

1 ■

ished in stature to an extra-

H^H

^ 1

ordinar>- degree. She may

^^^H

■

lose as much as a foot and

^^^^k

■

a half in height (Fig. 313).

^^^H

The gait of an osteomalacic

^^^H

1 I

patient is peculiar. In

^^^V

1 *

1 1

order to compensate for

1 ^^

\ fl

the approximation of the

1 «|pF

m fl

thighs brought about by

1 m

/ ^1

the collapse of the pelvis.

\ M

^^r ^H

the individual must turn

\ A

y ^^k

almost through a half-circle

B S

jm\ ^H

in order to bring one foot

m. ■

Xj^^^B

in front of the other. By

^B ■

xnH^^I

palpation of the pelvis ten-

^^ Wk .

■ H^^^l

derness upon pressure is
discovered over its anterior

Fti-. 11-1.— Ai,tlu.r's ca.^

of ojleniiulacia.

" " "

walls. The flexibility of

the pelvic bones may be

demonstrated by direct pressure,

and an internal examination

reveals, in the early

Stage of the

lisease, tlie peculiar beak-like

space behind the s>'

iphysis, and la

ter the almost entire oblitera-

tion of the pelvic outlet and canal

ay the sinking in of the pelvic

^^ walls. If it is possible to make a

satisfactory internal examina-

ANOMALIES IN THE FORCES OF LABOR, 453

tion of the pelvis, the low position and the projection of the
promontory at once attract attention, and the sharp angulation
on the anterior face of the sacrum can be felt. On account of
the exaggerated inclination of the pelvis, it may be necessary to
make an examination with the patient upon her side. An osteo-
malacic pelvis has been taken for a kyphotic, a Robert, a pseudo-
osteomalacic, a cancerous, or a fractured pelvis, but a careful,
methodical examination of the patient will always lead to a cor-
rect diagnosis.

Influence Upon Labor, — The results of labor in osteomalacic
pelves show that the obstruction is a serious one, although by
reason of the flexibility of the pelvis in some cases the head can
distend the pelvic canal sufficiently to pass through. In 85 cases
collected by Litzmann, 47 ended fatally. In another series of 128
cases the labor had a spontaneous termination in 27 cases, in 4
there was premature delivery, and in 5 abortion ; 4 times the
labor was naturally terminated ; in 8 cases version was per-
formed, in 4 the child was extracted by the feet, in 25 forceps
were employed, in 1 1 craniotomy was performed, and in 36
Cesarean section ; rupture of the uterus occurred in 5 women
before any operation was undertaken. In still another series of
cases reported from Milan, the flexibility of the pelvis was so
great that the child was delivered in only two instances by Cesa-
rean section.

The most successful treatment is the performance of Cesarean
section, and the operator should at the same time remove the
ovaries, or, what is better, perform a complete Porro operation. It
is beyond dispute that the cessation of sexual functions favorably
modifies or actually cures the disease.

Tumors of the Pelvis. — The commonest pelvic tumors are
bony excrescences, usually found over one of the pelvic joints.
The excrescences arc originally cartilaginous projections which
become ossified by an extension of bony tissue from the two
bones between which they lie. These exostoses may be found
over the sacro-iliac joints, over the crests of the pubis, at the
iliopectineal eminences, and over the promontory of the sacrum
(Figs. 315, 316, 317,318). They may attain the size of a pigeon's
egg, though they are usually not larger than a pea or nut. In
the exostoses occupying the seat of the pubo-iliac junctions,
directly above the acetabula, the bony growth is apt to assume
a sharp, thorny shape, projecting with its point into the pelvic
inlet. Kilian was the first to direct attention to this fact ;
he called a pelvis thus deformed '' acanthopelys'' (Fig. 319),
or a ''pelvis spinosa,'* Another possible scat for a bony pro-
jection is along the crests of the pubic bones, the exostosis

4S4

THE PATHOLOGY OF LABOR.

taking here the form of a long, sharp edge, and probably owing
its origin to an ossification of the attachment of the iliac fascia,
a transformation of tissue analogous to the ossification some-
times seen in Gimbemat's ligament. These bony outgrowths

Fig. 316.-

■ =)-i"liliysi5 (St-hai

are a serious obstruction in labor, not so much from their
encroachment upon the room of the pelvic inlet, as from
the sharply localized pressure which they exercise upon the
maternal structures and upon the fetal head. In the four cases

ANOMALIES f.V THE FORCES OF LABOK.

455

reported by Kilian, death, it was claimed, resulted in each case
from a perforated uterus. Other tumors of the pelvis obstruct-
ing labor are enchondromata, fibromata, sarcomata, carcino-
mata, and cysts (Figs. 314. 320). These tumors are rare, and

Fig. 318.-

round Ihe pelvic

(iiiudel

s collection).

their importance as obstacles in labor depends, of course, upon
their size. Cysts of the pelvis are formed usually in .sarcomata
and in enchondromata, or are hydatid cysts. Cancer of the
pelvic bones is always a secondary growth or is metastatic. It

4S6 THE PATHOLOGY OF LABOR.

may result in a number of smalt tumors in the bony pelvic walls,
or may take on the form of cancerous infiltration with a conse-
quent softening of the bones like that of osteomalacia. The
treatment of labor obstructed by tumors of the pelvis is ordi-
narily the performance of Cesarean section. There is one case
on record (Abernethy's) in which the tumor, an cnchondroma,
was removed by an incision in the posterior vaginal wall, bul in
the vast majority of cases these growths can not be reached or

Fig, 310.

fllchm).

safely excised. In 49 cases of labor obstructed by a pelvic
tumor, 50 per cent, of the women and 90 per cent, of the children
lost their lives (Winckel).

Fractures of the Pelvis. — Out of 13,200 fractures reported
from nine large hospitals in America and in Europe, but ^j of one
per cent, were fractures of tlie pelvis. When one considers that
almost all grave injuries of tlie pelvis end fatally, the rarity of a
pelvic deformity dependent upon a united fracture '
bone in a woman of child-bearing age may be 3

ANOMALIES IN THE FORCES OF LABOR. 457

frequently the fracture is found in the pubes, next in the ilium,
next in the ischium, next in the acetabulum, and least frequently
of all in the sacrum. The effect of a fracture of the pelvis upon
the shape and size of Its canal depends on the location of the
fracture, and the deformity may be due to distortion of the pelvic
walls, to excessive callous formation, or to ossification of the pelvic
joints nearest the seat of fracture. In a fracture of the acetabu-
lum the result of hip-joint disease, the head of the femur may

yig. 311.— Fnusure of the pelvis (Otlo).

Fig. 3IZ. — Frsclnrr of the actt&bulum in consequence of coialgia (Otto),

project into the pelvic canal (Fiy. 333). Fracture of the pubes
results in an irregular distortion of the pelvic inlet, most marked,
tjf course, on the injured side (Fig. 321). A fracture of the upper
portion of the sacrum may result in a spondylolisthetic deform-
ity (Fig. 323). I'racturc of the lower portion of the s.icrum is
followed by a dislocation of the lower fragment inward. In a
case under my observation the lower half of the sacral bone was
turned in at right angles to the rest of the bone by the pull of

458 THE PA THOL OG Y Of LABOR.

the pelvic muscles attached to it, A fracture of the sacral alae
may cause an oblique contraction of the pelvic inlet like that of
the Naegele pelvis (Fig. 324). Neugebauer ' reported an ex-

Fig. 324.— Fraciurc of the rieht n!» o( thi

traordinary c
there was uni

; of bilateral fracture of the pubic rami in which
with callous formation on one side and an ununited

" Jahreibericlit iib«r d. For

1. d, CeUele der Geliurub.," etc., *ol. iv.

ANOMALIES IN THE FORCES OF LABOR. 459

fracture on the other, the fragments moving on each other two
or three centimeters when the woman walked.

Caries and Necrosis. — The only effect of these diseases of the
pelvic bones is the production, in rare cases of tuberculosis of a
sacro-iliac joint, of an oblique contraction of the pelvis. When
the sacro-iliac joint is affected, the ultimate result is the same as
that produced by imperfect development of the sacral alae in a
true Naegele pelvis. There is loss of tissue, ankylosis of the
joint, and an arrest of development in the affected part if the
disease occurs in early childhood.

Ankylosis and Relaxation of the Pelvic Joints. — Synostosis
may develop in any of the pelvic joints ; in the symphysis it
occurs not infrequently, and often at an early age. A number
of operators have encountered difficulty on this account in at-
tempts to perform symphysiotomy. In otherwise unobstructed
labor synostosis of the pubic symphysis is not a serious condi-
tion, although it limits the slight expansion which every normal
pelvis should exhibit preparatory to and during labor.

If synostosis of the sacro-iliac joint develops in the indi-
vidual's early childhood, it is followed by ill -development of the
sacral alae on the affected side, and of that portion of the in-
nominate bone concerned in the formation of the joint, an
obliquely contracted pelvis of the Naegele type being the result ;
but such cases are rarer than those in which lack of development
in the sacral alae is the primary occurrence. If the synostosis
of the joint occurs after puberty, the effect upon the pelvis and
upon the course of labor is practically niL If both joints are
early ankylosed, a form of laterally contracted pelvis like the
Robert pelvis is the result. This kind of contracted pelvis is
rarer than the transversely contracted pelvis due primarily to lack
of development in the sacral alae.

The sacrococcygeal joint becomes ankylosed, as a rule,
between the thirtieth and fortieth years, but as the joint between
the first and second coccygeal vertebrae is ordinarily unaffected,
the pelvic outlet is capable of expansion during labor in its
anteroposterior diameter nearly as well as if the sacrococcygeal
joint were normal. Rarely, there is an ankylosis of all the coc-
cygeal joints as well as of that between the sacrum and the coccyx.
In these cases labor can be terminated only by a fracture of the
coccyx or a laceration of the sacrococcygeal joint. The ex-
pulsive forces of labor may be sufficient to cause the fracture,
and the bone has been heard to give way with a loud crack as
the head was passing through the pelvic outlet. This accident,
however, is more likely to be caused by the artificial extraction
of the head.

460 THE PA THOL OG V OF LABOR.

An abnormal relaxation of the pelvic joints may be a simple
exaggeration of the natural process by which the pelvic canal
is made somewhat expansible preparatory to labor. It is more
likely, however, to be due to some pathological condition within
the pelvic joints, as an inflammatory process followed, perhaps,
by suppuration, an accumulation of fluid within the joinl, osteo-
malacia, caries, or new growths. In pregnancy the pathological
relaxation of the pelvic joints may occasion some difficult>'' in
locomotion. During labor an exaggerated relaxation of the
joints predisposes to their rupture.

The SpoodyloiisUietic Pelvis. — The spondylolisthetic pelvis
^•as first described in 1839 by Rokitansky, who reported two
cases : Kiwisch and Kilian each followed with a description of a
^jecimen ; but we owe our knowledge of the condition mainly
to the indefatigable researches of Neugebauer, ^ who collected
more than ninet\' cases and specimens, and to the discoveries of
Lane, who has done much to clear up the etiology. The name
"spondylolisthesis'**- indicates the condition — a slipping do\m
or dislocation of the vertebne. To affect the pelvis the spon-
dylolisthesis must be in the lumbosacral region (Figs. 325-

J-/ '-^

Characteristics. — As the name denotes, there is a dislocation
of the last lumbar vertebra in front of the sacrum, the body of
the former slipping down in front of the first sacral vertebra, so
that its inferior border, or in adx-anced cases its anterior surface,
comes in contact with the anterior face of the sacrum, to w^hich
it becomes united by bony union. There is. also, of necessit\%
an exa^^enited lordosis of the lumbar vertebrae and a descent
into the :v!\ :c inlet <^f at least the fourth and third, and even of
the second. lumbar vertebrne. which diminish by their bulk and
anterior pro'ection the anteroposterior diameter of the pelvic
canal. It is onI\- the body of the last lumbar vertebra that is
displaced, vind not the arch, held fast by the low^er posterior
articular siir faces, nor the laminae surrounding the spinal cord ;
so that the latter does not necessarily suffer compression by the
displacement of the vertebrcie, although this result has been noted
in a few cases (I'ii;. 326). To allow the displacement of the

^ Fran.- 1 luiwii^ N'cui^obauer, " Hericht iiber die neueste Kasuistik und Utterm-
lur dor Spv>nd\lv>Ii^tlusis otc. , '* Zeitschrift f. GeburtshCilfe und GynJLkolc^e '*
IM. xwii, U. J. iS)?; »• Siv»ndyloIisthesis et Spondylizdme/* " R^sam^ des Re-
cherclu< liiteraires et {vrs<'iu lie depuis l88o jus(|u'en 1892," Paris G. Steinheil
iSoJ ; ** rontribiuitvi a la ratlu^genie et au Diagnostique du Bassin vici^ par le
iilissement vertebral.' '• Annales de Gynecologic," Feb., 1884; ** Zur Entwickc-
lun^^geschichto des sp<^ndyloli<theiischen Beckens und seiner Diagnose," Halle and
IV-irivit, iSSj, p. 204; see also '♦ Archiv f. Gynakologie," Bd. xx, H. I und Bd

XXI, 11. 2.

' (TTurt^i^of, vertebra, and b/iaOr^aiq^ a slipping out or down.

ANOMALIES IN THE FORCES OF LABOR. 461

body of the last lumbar vertebra the interarticular segment of
the spinal arch and the pedicles are enormously lengthened from
behind forward and are bent at an angle downward (Fig. 327).
After a time this segment may exhibit a transverse fracture or a
solution of continuity from pressure and attrition. The deform-
ity is always gradual in development. If it begin during the
child-bearing period, successive labors become increasingly diffi-
cult. As the vertebra descends, it pushes the sacrum backward

Fig. 327. — Last lumbar
Terlebra of spondylolisthesis (a),
crjiitrasleil with n normal hflh
lumbar vertebra (Neugebauer).

and downward, and with it depresses the posterior portion of the
pelvic brim. To compensate for this movement the anterior
half of the pelvic brim rises and the height of the symphysis
is increased. This movement of the pelvis diminishes very
markedly its inclination, and disturbs the normal relationship
between the bones and the soft structures that overlie them.
The base of the triangle formed by the pubic hair in women is
well below the upper edge of the symphysis, and the external
genitalia are pulled so far forward that the vulvar orifice is

462 THE PATHOLOGY OF LABOR.

directed anteriorly as the patient sits or stands. There are, more-
over, the same displacements of the pelvic bones that are seen in
kyphosis— 7a rotation backward of the sacrum on its transverse
axis ; a rotation outward of the upper portions, and inward
of the lower portions, of the innominate bones on their antero-
posterior axes. The descent of the lumbar vertebrae drags the
large arteries of the lower trunk into the pelvic inlet, so that the
iliac vessels and the bifurcation of the aorta may be felt in a
vaginal examination. The degree of contraction in the conjugate
diameter of the inlet depends upon the descent of the last lumbar
vertebra and the degree of the lordosis. The contraction is usu-
ally not excessive, but it may be so great as to preclude the pos-
sibility of the engagement of the fetal head.

Etiology. — The etiology of spondylolisthesis at the lumbo-
sacral junction is still obscure. It has been attributed to direct
injuries of, and to faults of development or ossification in, the
interarticular segments of the spinal arch. It is certain that
these are predisposing causes, but the observations of Lane
appear to demonstrate that the commonest cause of the deformity
is an exaggerated pressure from the trunk above exerted often
upon healthy bone. As a result of this pressure a joint is formed
in the intervertebral disc, and the interarticular segments of the
last lumbar vertebra undergo stretching, pressure, angulation,
and atrophy until the bone is actually severed. Following or
accompanying these changes in the arch, the body of the last
lumbar vertebra is displaced further and further downward and
forward. Spondylolisthesis has followed an injury', presumably
a fracture, of the lumbar vertebrae.

Diagnosis. — The diagnosis of a spondylolisthetic pelvis is not
easy ; it can be made only by close attention to the patient's
history, by a careful observation of her appearance, by an inter-
nal and external examination of the pelvis, and by pelvimetry.
In the history of the case it ma}' appear that the individual was
the subject of a serious accident, such as a fall from a height or
a fracture of the pelvis by the passage over it of a heavy weight,
or it may be learned that she has carried excessively heavy bur-
dens for a long time. The woman's height is diminished and
the length of the abdomen is shortened. Viewing the patient
from behind, there appears what is called the saddle-shape or
" sway " back, the lumbar vertebra projecting visibly far forward
and being displaced downward, throwing into bold relief the
posterior superior spinous processes and the rims of the iliac
bones, and producing quite a deep furrow along the course of
the spinous processes of the lumbar vertebrae. The apposed
articular processes of the first sacral and the last lumbar verte-

ANOMALIES IN THE FORCES OF l.ABOH. 463

bn stand out as button-shaped prominences on the inner surface
of the posterior rims of the ilia. The buttocks are flat and are
pointed below, giving to the region a cordiform appearance. In
front there is a pendulous belly ; a deep crease is observed run-
ning across the lower abdomen a short distance above the sym-
physis. Laterally, the floating ribs are seen almost to rest upon
the crests of the ilia or actually to sink between them, and the
soft structures of the flanks arc thrown outward in prominent
folds. The trunk is shortened, and the limbs appear relatively
too long (Fig. 338). The patient's body being thrown forward
by the deformity of the spine, an effort to maintain an cquilib-

Fig. 328 — BiL'isky's case of sponiiylolisthi

rium is made by carrying the shoulders far back ; as the indi-
vidual walks, a disposition to fall forward may be noted, and she
will state, perhaps, that she is unable to carry any load upon her
arms in front of her body, for fear of toppling over upon her
face. She may also complain of a grating sensation and sound
in the small of the back (crepitus). The gait is peculiar ; the
toes are not turned outward, and the feet are swung around each
other so that the foot-prints fall in a straight line. Upon an
internal examination of the pelvis, — best conducted, according to
Neugebauer, in an upright or lateral position, — the lordosis of
the lumbar vertebrje is at once discovered. The angle formed
by the attachment of the la.st lumbar vertebra to the sacrum
lay be detected with ease, and it should be noted that the body

464 THE PA THOL OG Y OF LABOR,

of this vertebra does not possess lateral projections, transverse
processes, or alae. By their absence one is sure that he is not
feeling a projecting promontory. Pulsating iliac arteries may be
felt, and it is possible even to reach the bifurcation of the aorta,
— as first pointed out by Olshausen, — ^but this symptom is not
pathognomonic. It is possible to reach the bifurcation of the
aorta in a vaginal examination in the extreme lordosis of some
rachitic pelves and of the osteomalacic pelvis, in lumbosacral
kyphosis, and in some cases of dorsolumbar kyphosis.

The external palpation of the pelvis reveals its decreased
inclination. A measurement of the pelvis will show a marked
diminution in the external conjugate diameter, an increased
height in the symphysis pubis, an increased distance between the
posterior superior iliac spines, and a diminished distance between
the anterior iliac spines and the crests. There is also some
diminution in the diameters of the outlet. The internal conju-
gate diameter must be measured from the lumbar vertebra near-
est the symphysis pubis, usually the fourth. This is called the
"false " or " effective " conjugate diameter of the spondylolis-
thetic pelvis. On account of the decreased inclination of the
pelvis it is not necessary to subtract more than the ordinary sum
from the diagonal conjugate. In fact, the diagonal conjugate
may approach very nearly the length of the true, or may actu-
ally measure less than it.

I)ifluc7icc Upon Labor. — The influence of a spondylolisthetic
pelvis upon labor is that of a flat pelvis. The obstruction in
the former may be overcome more easily on account of the bow-
like shape of the projecting vertebra and the coincidence of the
uterine and pelvic axes. The obstruction to labor depends
entirely upon the projection of the lumbar vertebrae. This pro-
jection may be so slight as scarcely to influence the progress at
all, or it may be so great as to make delivery by the natural
channel quite impossible. There is noticed in labor something
of the same mechanism that is seen in the flat pelvis for the pur-
pose of overcoming the obstruction — namely, decreased flexion,
transverse position, and exaggerated lateral inclination of the
head. On account of the forward dislocation of the external
genitalia and of the pelvic floor, lacerations of the latter are the
rule, and the tears arc often complete into the rectum. This
liability to injury is explained by the fact that the presenting
part impinges directly upon the middle of the pelvic floor as it
descends the birth-canal, instead of bcinix directed forward to the
vulvar orifice. l^^istuLx of the anterior vaginal wall are likewise
common, from the localized pressure to which this region is
subjected while the head is passing the obstruction at the inlet.

ANOMALIES /.V T//E FORCES OF LABOR. 465

The presenting part is thrown forward by the projecting ver-
tebr;e, and is received upon tlie prominent ridge of the pubic
bone, greater in height and higher in situation than in the nor-
mal pelvis.

Treatment of Labor Obstructed by Spondylolisthetic Pelvis. —
The man^ement of labor in these cases is governed by the same
principles that obtain in the management of labor in a flat pelvis.
If the effective conjugate is over 9.5 cm., the woman can be
delivered spontaneously, by forcep.s, or by version. With an
effective conjugate of bctwi;en 7 and 9.5 cm., the induction of

premature labor and the performance of symphysiotomy must
be considered ; or craniotomy should be done if the child is
dead. If the effective conjugate is well under 7 cm., delivery
must be effected by a Cesarean section. These rules presuppose,
of course, a child of average size.

Kyphosis. — The kyphotic pelvis was first adequately de-
scribed in 1865 by Breisky. although its peculiarities had been
recognized before by Litzmann in 1861 and by Neugebauer in
1S63. The condition was called by Herrgott " spodylizema,"
a name adopted by Neugebauer and others (Figs. 330, 331).

466 THE PATHOLOGY OF LABOR.

Characteristics. — The degree of deformity in a kyphotic pel-
vis depends upon the situation of the hump : tlie nearer this is
to the sacrum, as a rule, the greater is the deformity in the
pelvis. Lumbosacral kyphosis is almost as frequent as the
lumbar and dorsolumbar combined. There is a compensating
lordosis of the lumbar spine, but not enough to keep the center
of gravity of the trunk from being too fer forward. In conse-

Fig. li±. — Kyjilinsis : grealrat
tnnsvcnp diamcicr ai outlet. 7 cm.
(MQilcr Musruro. Cullt^e of TbfA-
ciiDS, Philadelphia).

quence, the weijjht of the trunk is transmitted in a direction from
before backward, so that the sacrum is rotated on its transverse
axis in a direction the reverse of that seen, in rachiti.s — namely,
backward and scarcely ai all downward. The result of this
movement is to make the sacrum straighter, narrower, more
curved from aide to side, and longer { Rg. 330) ; to pull the pos-
terior supennr spin. JDS processes of the iliac bones closer to-

ANOMALIES IX THE FORCES OF LABOR. 467

gether, and to separate the anterior spines more widely. The
diminished width between the posterior superior spinous pro-
cesses is caused partly by the pull of the sacro-iliac ligaments.
The sacrum can not move in any direction without dragging the
ilium on each side by these ligaments, thus approximating their
upper posterii-r .surfaces. The iliminution of the interspinous

tig. 33J

measurement posteriorly depends also upon the narrowness of
the sacrum. To compensate for the movement of the upper
portion of the sacrum backward, the lower portion of the bone
projects forward, into the pelvic outlet. To preserve the body
from falling forward, the knees and thighs are slightly flexed and
the pelvic inclination is almost entirely lost. This posture puts

468 THE PATHOLOGY OF LABOR.

the iliofemoral ligaments on a stretch, which pull outward the
upper portions of the innominate bones. To compensate for
the movement outward of the iliac bones the lower segments of
the innominate bones move inward upon the pelvic inlet ; in other
words, there is a rotation of the innominate bones upon their an-
teroposterior axes. The result of these movements in the pelvic
bones is to enlarge decidedly the pelvic inlet in its anteroposterior
diameter, and to contract the canal toward the outlet, where the
diminution of the diameters is most marked
in the transverse (Fig. 331),

In the cases of lumbosacral kyphosis
the upper portion of the sacra! bone may be
involved in the necrotic process and the
sacrum may exhibit deformities by destruc-
tion of its tissues (Fig. 337). The Other
characteristic defonnities of the kyphotic
pelvis are most marked in this type, unless,
as in one instance, the body is bent almost
double, and it is necessary to rest the anterior
portion upon an artificial support, as a cane.
In this case the pelvis, although relieved of
tile weight of the trunk, is obstructed by
the overhanging lumbar vertebrse to such a
degree, perhaps, that the inlet is practically
obliterated (pelvis obttcta). In all cases of
exaggerated lumbosacral kyphosis the pro-
jecting lumbar spine blocks the pelvic inlet
and seriously obstructs labor. The conju-
gate diameter must be measured to the
lumbar or even to the dorsal vcrtebrjc, and
1.S exceedingly short. In 2 1 labors compli-
cated by this deformity of the pelvis, 66 per
cent, of the mothers and 75 per cent of the
cliildrcn were lost (Winckel).

Influence on Labor. — The influence of
'**"*■ the kyphotic pelvis upon labor is usually

not felt until the presenting part has de-
scended to the pelvic floor. In consequence of tlie shortened
perpendicular diameter of the abdominal cavity there is always
a tendency to a transverse position of the fetus m ulero, but
this position is ordinarily corrected by the first few labor-pains.
The head presents in 95 percent, of cases, the breech in 2 percent,
accordingto the statistics collected by Klein,' embracing 173

"Archiv f. Gyti." Bd, I. II I.

ANOMALIES IN THE FORCES OF LABOR. 469

births in 95 women. When the head arrives at the pelvic floor, if
the occiput is directed backward, as it is in a third of the cases,
anterior rotation will very likely be prevented and there will be a

i"**'».

persistent posterior position. A posterior rotation of the occiput
originally directed anteriorly is not rare. It occurred in five of
Klein's cases and in one of the author's. If the occiput is

470

THE PATHOLOGY OF LABOR,

directed anteriorly, the transverse diameter of the head may be
caught between the approximated spines or tuberosities of the
ischiadc bones, and labor be brought to an indefinite standstill
(Figs. 335, 336). The head usually enters the pelvis obliquely or
transversely. Rotation only occurs as the head emerges from the
outlet. Face presentations occur in a large proportion of cases
— four per cent, of the head presentations.

Management of Labor in Kyphotic Pelves. — An exact meas-
urement of the pelvis is essential to a determination of the proper
means of delivery. If the child is of normal size, pregnancy
may be allowed to go to term in pelves measuring 8.5 cm, and
more in the transverse diameter of the pelvic outlet Any
asymmetry of the ischia will constitute a serious complication,
necessitating operative interference that might be avoided in a
symmetrical pelvis with smaller diameters. Below 8.5 cm, down

f'e 33;. — Lumixisflcrfll kvphosLs (pi

to 6 cm. in the transverse measurement of the outlet, labor
should be induced at the thirty-sixth week. With a measure-
ment less than 6 cm. Cesarean section is indicated absolutely.
If the woman is first seen in labor at term, the head, if it is
presenting, should be allowed to descend to the pelvic floor
and the woman should be encouraged to make vigorous ex-
pulsive efforts. If the occiput shows a disposition to rotate
posterioriy, the movement should not be interfered with, for
the greater bulk of the occipital region will find more room pos-
terior to the tuberosities than it will anterioriy. The author has
seen an occipi to-anterior position of the vertex remain stationar^-
until the head rotated from an anterior to a posterior position,
when the vertex was expelled without further difficulty. With
a transverse diameter to 8.5 cm. spontaneous delivery may be

ANOMALIES l.V THE FORCES OF LABOR.

471

possible, though it may be necessary to use forceps. Below 8. 5
cm. the forceps may be tried cautiously, but symphysiotomy is
hkely to be required. In no other form of contracted pelvis is
this operation so successful. Klein found, by experiments on the
cadaver, that by a separation of the symphysis to 6 cm. In a
kyphotic pelvis, the tuberosities moved 4.5 cm. further apart.
Symphysiotomy, therefore, might be expected to be successful
in a transverse diameter of 6-cm. or even a trifle less. If the child
is dead or if the graver obstetrical operations are not admissible,
craniotomy should be performed, in case the forceps fail. In
employing forceps the operator must remember the dangers of
rupture of the symphysis and deep tears of the vaginal walls to
which kyphotic subjects are particularly liable. Version has
given the worst results of all the obstetrical operations in kyphotic
pelves. It is, therefore, as a rule, contraindicated. Klein's

fig. i

statistics show that in fifty-eight to sixty per cent, of cases the
labor must be terminated by operative interference.

Diagnosis. — The diagnosis of a kyphotic pelvis presents no
difficulties. The hump-back is obvious, and the history is easily
obtained that the spinal deformity was developed early in life.
The pelvic measurements diagnostic of this deformity show an
increased separation of the iliac crests and the anterior spines, an
abnormally long conjugate diameter of the inlet, a diminished
distance between the posterior superior spines, an approximation
of the tuberosities of the ischiatic bones, and some diminution in
the anteroposterior diameter of the pelvic outlet. The buttocks
are flat and pointed below, the external genitalia are displaced
forward and upward, and the upper edge of the symphysis is
above the upper edge of the pubic hair. Care should always be
exercised to detect asymmetry in these pelves, to discover an

474

\:y cr 1.4/io/;:.

y^*.

. .-.LVllI. .

ANOMALIES /.V THE FORCES OF LABOR.

473

extra pressure exerted upon it by the head of the femur. 7"he
actitabuliim on this side is displaced anteriorly and upward ; the
symphysis is pushed over on the opposite side. The degree of
asymmetry is rarely sufficient to constitute an obstruction in
labor. The scoliotic pelvis is. however, most often rachitic, and
in addition to the asymmetry of scoliosis there may be the con-
traction of a rachitic pelvis (Figs. 339, 340).

Kyphoscoliosis. — In a combination of kyphosis and scoliosis
of the spinal column the pelvis will show, perhaps, the combined

f'B' 339.— Scolms
pelvis: C. V,, 8.25 cm.
on a dead child (authur'

features of both, but the kyphosis, being of rachitic, not of
carious, origin, vvill not be angular, and will be situated high in
the dorsal region, where it may be compensated for entirely by
lumbar lordosis (Figs. 341, 343 ). The kyphoscoliotic pelvis
is usually an asymmetrically contracted rachitic pelvis (PI, 8,
Fig. I).

Lordosis. — Primary lordosis not the result of pelvic deform-
ity or of spina! disease is very rare. Aside from some illustra-
tions of it in an article by Neugebauer (Joe. cil.), the writer
_.knows of no reference to the subject except his own (PI. 8,

474 '^'"^ PATiioLocr of labor.

i.iculi<jsi, ( Leupuld}.

I, Lumbodorsal kyphoscoliosis (Schauta) ; i, Itmiosis from paralysis of spinal muscles
(■uthor's cue] : 3, skeleton of a girl with coxiil|;iB (Medical Museum, Uni>ersilyof Penna.) ;
4, rear view. 5, side view, of obliquely CDHtractrd pelvis.the result of tubervulouB disease in ooe
knee-joint (author's caie) ; 6, scoliosis from unilaterul ntropby of spinal muscles (author's cue).

{ Fig.

I insui

AA'OMALIES IN THE FORCES OF LABOR.

2).' It may readily be seen what an influence this deformity
lid have upon coition and parturition, and how it might be an
insuperable obstacle to the natural completion of the latter.

5. Anomalies Due to Diseases of the Subjacent Skeleton. —

Coxalgla. — The deformity of the pelvis due lo coxalgia in early
childhood is of two types. In one there is an oblique contraction
by a displacement of the innominate bone on the healthy side up-

476

t'ig, 34!- — Skeleloii u( wiimaii slioisri in ligure J42, wiio died in cunsequence of

ANOMALIES IN THE FORCES OF LABOR.

477

ward, backward, and inward, on account of the pressure of the
femur, the weight of the body being received mainiy upon the
sound leg. This fonn of coxalgic pelvis, as a rule, presents no
serious obstacle to delivery unless it is associated with a rachitic
deformity (Fig. 345)- Special attention, however, should always
be paid to the length of the conjugate diameter of the inlet,
and to the transverse diameter of the outlet. In the other
variety of coxalgic pelvis the deformity is also an oblique con-
traction, but it is the bone on the diseased side which is driven
inward upon the pelvic canal. This displacement of the innomi-
nate bone is the result of an arrested development on the corre-
I spending side of the pelvis, and is usually associated with an

I atrophy of the sacral ala and an ankylosis of the sacro-iliac joint.

I The contraction of the pelvic canal is much more serious in this

F>E- 345—

;ic pelris (MQ(ler MuKani, Collie of fTiysicians. Philadelphin),

form, and there may be all the difficulties in labor encountered
in the true Naegele pelvis.

Luxation of the Femora. — Dislocation of the thigh-bones, if
congenital or occurring early in childhood and not corrected,
has some effect upon the size and shape of the pelvis, but usually
not enough seriously to obstruct labor. If one thigh is dislo-
cated, the weight of the body may be thrown mainly upon the
other leg, and this may produce an oblique contraction of the
pelvis of the kind already described. If the thigh-bone is
displaced forward, the anterior half of the pelvis may be
driven in a little upon the pelvic canal, and the head of the thigh-
bone, as in one case reported, may project over the horizontal
ramus of the pubis into the pelvic inlet (Fig. 346). In the con-
genital lu.^ation of both femora backward upon the iliac bones
there is an excessive rotation forward of the sacrum, an increased
width of the pelvic canal, and from the drag of the attached

480 THE PATtfOLOGV OF LABOK.

ties of the ischia are separated. Minor deformities of little prac-
tical importance may be the result of unilateral or bilateral club-
foot or of the bowing of one or both lower extremities. In the
former there is an increased inclination of the pelvis, and approxi-
mation of the acetabula and of the ischiatic tuberosities, and a
narrow pubic arch (Fig. 350).

Fig. sso-r*'

ity, the result of doul.lt cliib-fool tMeyer).

6. The Management of Labor Obstructed by the Com-
monest Forms of Contracted Pelvis: a Simple Flat, a Rachitic
Flat, and a Generally Contracted Pelvis. — There is nothiny in
medicine requiring more experience and good judgment than the
management of labor obstructed by a contracted pelvis. It is
extremely difficult to formulate hard-and-last rules for the guid-
ance of the inexperienced when so many factors must be taken
into account. The rules given below govern the writer's prac-
tice in the average case, but due attention must be paid to the
history of past labors, the size of the child, its development,
and the compressibility of its head, the age of the woman,
the build of both parents, and the probable strength of the ex-
pulsive forces, greatest in the primipara and less with successive
tabors.

If the diagnosis of 3 conjugate diameter of 9.5 cm. or less
is made during pregnancy, the physician must choose either
induction of premature labor, or forceps, version, symphysiotomy,
or Cesarean section at term. If the conjugate diameter meas-
ures as low as 9.5 cm., it is a safe plan to induce labor four
weeks before the expected termination of pregnancy. This
course entails no additional risk upon the child if its parents are
in a position to afford it the best care and nursine. and it ia much
the safest plan for the mother, the induction

ANOMALIES IN THE FORCES OF LABOR. 48 1

erly, having no maternal mortality. ^ It is true that many women
with a conjugate of 9.5 cm. can deliver themselves without
difficulty at term. Spontaneous delivery with a measurement
as low as eight centimeters and under has been recorded. But
the majority of women with a conjugate of 9.5 cm. will ex-
perience abnormal delay and difficulty in labor, with added risk
to themselves and to their children ; and in a certain propor-
tion of cases a conjugate of 9.5 cm. proves an insuperable
obstruction in labor, and is the cause of ruptured uterus or death
from exhaustion in the mother or of injury to the child's brain.
These results are to be feared especially if the child be over-
grown or if the mother's expulsive powers be weak — ^two con-
ditions impossible to predict with absolute certainty. For these
reasons, then, the rule to induce premature labor when the con-
jugate is at or below 9.5 cm. is a safe one. If the conjugate
measures between seven and eight centimeters or more, the most
successful treatment is still the induction of premature labor at
the thirty-sixth week. By this plan the majority of women with
a conjugate of eight centimeters or a trifle less will be delivered
spontaneously or with no more serious operation than the appli-
cation of forceps. If the conjugate measures seven centimeters or
less, the induction of premature labor four weeks before term
can not be expected of itself to secure a spontaneous delivery.
Either symphysiotomy in suitable cases or Cesarean section
would, as a rule, be required in addition. In such cases, there-
fore, the physician may wait until term or shortly before it, so
that his operation shall secure the birth of a child vigorous in
development. With a conjugate diameter of the superior strait
at and below 7 cm., the woman should be allowed to go to
term and should usually be delivered by Cesarean section.

If the physician sees the patient for the first time in labor, or
only discovers the deformity after labor has begun, he must
choose one of the following modes of delivery : A waiting policy,
to allow the engagement of the head by natural forces ; the ap-
plication of forceps ; the performance of version, symphysiotomy,
or Cesarean section. While the child is alive, craniotomy
should not be considered. The selection of the best mode of
delivery in contracted pelves is one of the most difficult problems
in obstetrics. If the patient is a primipar^ and the conjugate is
above nine centimeters, natural forces will, in the majority of cases,
provided the fetus be not overgrown, secure the engagement of

* This statement is based upon the writer's experience in private practice, and
not apon hospital statistics. It does not hold good for labors induced before the
thirty-sixth week.

48 2 THE PA TliOL OGY OF LABOR.

the head,^ although it may be by the expenditure of considerable
force, after long delay, and only after prolonged molding and an
adaptation of the size of the head to the size of the contracted inlet
by apparent anomalies in the position and flexion of the former.
It is wonderful how successfully an obstruction may be overcome
even in cases of contracted pelves with a conjugate of eight centi-
meters or less. But while waiting for spontaneous delivery, the
physician may see the uterus suddenly rupture or may find the
child's head after birth seriously injured. It is permissible in
most cases to wait for the full, or almost full, dilatation of the
OS, keeping careful watch upon the woman's pulse, temperature,
and general condition, upon the situation of the contraction -ring
and the distention of the lower uterine segment, and taking
whatever operative measures may be required in plenty of time
to forestall the possibility of uterine rupture. The application
of forceps to the head above the superior strait for the purpose
of securing its engagement by forcible traction should in general
be condemned, but it must be admitted that there are important
exceptions to this rule. If one is skilled in the application of the
forceps, bears in mind the transverse position of the head, and
can gage the degree of traction which may be exerted without
injury to the child's skull or to the maternal soft structures, he
will occasionally succeed in securing an engagement with the in-
strument that would otherwise, perhaps, be impossible. As a
rule, however, it is safe to say that the choice lies between in-
action and the performance of version. By the latter operation
the smaller end of the wedge represented by the child's head is
engaged in the contracted inlet, and there can be exerted upon
the head coming last, both by traction on the body from below
and by pressure on the head through the abdominal walls above,
a degree of force that is impossible with forceps. It is well,
however, to bear in mind the danger entailed upon fetal life
when version is i)erformed in a contracted pelvis. There is a con-
siderable risk 2 that the head will be retained long enough above
the superior strait, or in it, to asphyxiate the child beyond re-
vival.^ Or the pressure upon the head by the pelvic walls may

1 From i88l to 1887 there was spontaneous delivery in 163 out of 444 cases of con-
tracted pelvis in the Vienna Hosj^ital, and in 47 women the conjugate was not above
8.5 centimeters (Braun u. Ilerzfeld, " Der Kaiserschnitt u. seine Stellung zurkiinst-
lichen Kriihgeburt, \Vendung, atyi>ischen Zangenoperationen, Kraniotomie bei u. zu
den spontanen (Jeburten," Wien, 1888, ii, p. 144). In the Moscow Maternity there
were 84 contracted pelves among 4000 births in 1894; 71 percent, of these cases
were spontaneously delivered (Kuster, ** Centralblatt f. Gyn.," No. lo, 1895).

2 The infantile death-rate will be at least twenty -five per cent., or more likely
higher (Nagel, ** Die Wendung bei engen Hecken," ♦* .Archiv f. Gyn.." Bd xxxiv).

' Nagel reports sixty cases of version for contracted pelvis, with a fetal mor-
Ulity of twenty-five per cent. (i^/V/., p. 168).

ANOMALIES IN THE FORCES OF LABOR.

483

I fracture the skull and crush the brain, and the force employed in

I extraction may break the neck. If in the judgment of the oper-

J ator the danger entailed upon the fetus by version is too great,

natural forces having failed to secure engagement, and if he has
tried the forceps cautiously without success, his choice must rest
between symphysiotomy and Cesarean section. The former will
be selected only in isolated instances with most favorable con-
ditions if the conjugate is above seven centimeters ; the latter,
always in cases of greater contraction than seven centimeters, and
occasionally as a relative indication with a conjugate as large as
8.5 cm. These rules for the treatment of labor obstructed

by a contracted pelvis presuppose, of course, a fetal body and
head of average size. This point must always be investigated
carefully by abdominal palpation, although it is most difficult to
determine. ' If the physician ha.<? reason to believe that the child
is oversized, he must allow himself sufficient latitude to insure
delivery. This advice applies particularly to cases in which

' The relnlWe siie of head and pelvis may l* delennincd approniniBlely by the
melhod of Mailer and Schali. The fetal head is ^ra<p«l betvreen (he extended
fingers of (he phyjicinn, and ia pressed down sleadily and for some lime upon the

SIvic brim, the direction of the force cmnciding with the axis of the superior strait,
this mODieuver succeerli in pressing the head within the pelvis, then naturnt forces
will rarely tecute engagemeal. If it faiti, the convene by no means necessarily

484 THE PA THOL OG Y OF LABOR.

the operator is in doubt whether to select symphysiotomy or
Cesarean section. If, on the one hand, there is good reason to
fear that the child can not with safety to itself be extracted
through the birth-canal after the former, his choice should rest
upon Cesarean section. On the other hand, if the child is under-
sized (a condition easier to detect by palpation than is overgrowth),
spontaneous delivery may be expected through a pelvis that would
not permit the passage of a child of normal size. Klein and Wal-
cher declare that by raising the buttocks and letting the limbs
hang down as much as possible the conjugate diameter is length-
ened by almost a centimeter. Clinical tests of the method are

fig- 352. — The Walcher posture.

described, attended, apparently, with success.^ The Walcher
posture has been indorsed by a number of observers in Germany
and in other countries. The author has found it of decided ad-
vantage, and would recommend its sy.stematic trial.

7. Obstruction to Labor on the Part of the Soft Maternal
Structures in the Parturient Canal. — Congenital Anomalies of
Development In the Uterus. — A double or septate uterus may com-
plicate labor in .several ways. The bulk of the unimpregnated
half may ob.struct tieliverj'. especially if this half is retroverted

' •' Zcitschtifl f. (;<-l.iirl=., u. Cyn," l!ii. x»i. II. I. and ■• Med. Korresp. Bl.

I and i

r veloc

AXOMALtES m THE FORCES OF LABOR. 485

and is increased considerably in size in sympathy with the de-
velopment of the impregnated side, and is hardened in consist-
ency by sympathetic contraction during the labor-pains. The
septum itself may prove an obstacle in labor, and sometimes
labor is obstructed by the strong vesicorectal ligament that runs
between the horns of a bicornate uterus. If the placenta is at-
tached to the septum, alarming hemorrhage may occur from im-
perfect contraction of the sparsely supplied muscular fibers in it.
Mai presentations of the fetus and a faulty direction and insuffi-
cient power of the expul.sive force are common. Rupture of the
uterus is to be feared on account of the ill-developed uterine walls.
laceration of the septum frequently occurs. It has been noted that
a decidual membrane may be retained within the non-pregnant half
of the uterus, where, undergoing putrefaction after delivery, it may
give rise to septic infection. Tlierc seems also to be a disposition
to the retention of membranes in the pregnant side of the womb.
Retention of the placenta is not uncommon, partly because of
insufficient expulsive force, partly on account of its situation. —
perhaps attached in both divisions of the uterine cavity, The-
vard* reports the retention of the placenta in a double uterus for
fifty days, when it was spontaneously discharged. It has hap-
pened, in cases of double uterus and vagina, that the physician ex-
amined the wrong side, and was ignorant of the progress of labor
until the child was about to be born ; also that he examined
first one side and then the other, finding first a dilated and then
a contracted external os.

In one woman with a double uterus there was noted a dis-
position to become pregnant in regular alternation first on one
side and then upon the other. ^

Closure and Contraction of the Cervix. — The cervix may ob-
struct labor by reason of atresia, cicatricial infiltration, contrac-
tion, and rigidity, or there may be longitudinal or transverse
septa in the canal. Atresia of the cervix in a pregnant woman
must, of course, be acquired after impregnation i^cmtglutinatio
orijkii uteri cxtenii) ; it is rarely, however, complete. There is
always an indication at least of the external os in a dimple evi-
dent to the sense of sight if not to that of touch. By pressing
upon this point with a finger-nail or with the tip of a uterine
sound, a small artificial opening may be made. Directly this is
secured, the dilatation of the external os proceeds in a remark-
ably rapid manner, although hours of vigorous labor-pains
before had been insufficient to begin it. If this plan fails, a

' " NoaTclIes Archives d'Obstilrique el dc Gyntcologie," 1890, p. 640.
' SoulhenniiiiEi. " Ilerlinei med. Wochen.," 1879, 41.

486 THE PA THOL OG Y OF LABOR.

crucial incision must be made in the cervical tissues at the site
of the external os. The dilatation of the small opening thus
made is then left to nature. If hemorrhage follows the incisions,
the bleeding points should be secured by sutures. An active
treatment is always called for. Without it the uterus may rup-
ture, the vaginal portion of the cervix may be torn off from the
womb, or the head may emerge completely covered by the
enormously distended cervix as by a caul. ^ Cicatricial contrac-
tion or infiltration of the cervix is the result of old, unrepaired
tears, of operations upon the cervix, of cauterization, of syphilis,
or of cancer. In the first instance the resistance to dilatation is
scarcely ever great, and what there is may be almost always
overcome by hydrostatic dilators, by the application of the forceps
and forcible delivery of the head through the cervical canal, or
by the performance of version followed by rapid extraction. If
the cicatrices are of syphilitic or of cancerous origin, the obstruc-
tion is more serious. It may be overcome by radiating incisions
with scissors or with a probe -pointed bistoury, but it is not un-
likely to demand the performance of Cesarean section.

Rigidity of the cervix is seen normally in all primiparae, and
to an exaggerated degree in elderly primiparae. It yields often
to copious douches of warm water directed against the anterior
wall of the cervix and frequently repeated — ^as often as once
every fifteen minutes if necessary. Chloral internally and bella-
donna ointment applied directly to the cervix have been recom-
mended, but these remedies are not to be depended upon except
in the slight rigidity characteristic of all primiparae. If there is
delay in such cases, fifteen grains of chloral every fifteen minutes
for three doses may advantageously be given. An anesthetic,
after all, is the most valuable medicinal agent that we possess for
the relaxation of this as well as of other rigid tissues. The rigid
cervix yields at length to the steady pressure of the presenting part,
and it is rarely necessary on account of rigidity alone to resort to
artificial dilatation or to incisions. In the course of a slow dilata-
tion of the cervical canal and external os the anterior lip may be-
come incarcerated between the head and the pelvic walls. In con-
sequence of the pressure and the disturbance of circulation in the
part the cervical tissues rapidly become edematous, and the bulk
of the anterior lip becomes so great as actually to constitute a
mechanical obstruction to the descent of the head. It is usually
possible in such cases to push up the anterior lip over the head
and above the symphysis in the intervals between the pains. If
there is hypertrophy of the anterior lip in consequence of an old

* Jeutzen, " Archives de Tocologie," Paris, 1890, H. 8.

I lacei

ANOMALIES IX THE FORCES OF LABOR.

487

laceration and eversion. or, all tlie more, should there be hyper-
trophy of the whole infravaginal portion of the cervix, the ob-
struction may become quite serious, and it may be impossible to
push the cervix above the head. In such cases forcible traction on
the forceps or radiating incisions in the cer\'ix maybe necessary.
Longitudinal septa in the cervical canal are usually seen with
duplicity of the uterine cavity from failure of the Miillerian ducts
to fuse completely. Occasionally the lack of fusion is confined
to the cervical canal alone (ittcnis hifor'ts). Rarely, transverse
septa have been found in the cervical canal.' It may be neces-
sary to cut them before the child can pass into the vagina.

Fig. 3S3' — Double vagina.

Closure and Contraction of the Vagrlna or Vulva. — ^There may be
obstruction of the lower birth-canal by longitudinal and trans-
verse septa, by cicatrices, by hematomata, by partial atresia, es-
pecially at the upper third of the vagina, by unruptured hymen,
by anus vaginalis, by vaginal tumors and c>'Sts, by cystic and
solid tumors of the vulva, by enlai^ed caruncula: myrtiformes,
by varices, by vaginismus, by congenital narrowness of the

488 THE PATHOLOGY OF LABOR.

vagina and vulva, and by rigidity of the tissues, especially in
elderly primiparar.

L OHgitudinal and Transicrsc Septa. — These are not ordinarily
very dense in structure, and they give way commonly before the
advance of the presenting part. If they do not yield, it is easy
to cut them in one or more places, the hemorrhage being con-
trolled, if necessary, by sutures afterward, or, in the case of trans-
verse septa, by a double ligature applied first, the septum being
cut between, though there is not much tendency to bleeding
even in those as thick as one's finger (Fig. 354).

I^'g' 355-— -^"us "^tibularis. Dot-
ted lines abow ihe limit of mucmra
membrane-. Ibickenetl skin mukt tb«
nomul site at the anus (Dickiiuon).

Hematomata. — Hematomata of the parturient tract usually
occur at the vaginal orifice, and most often between the birth of
twins. They are considered here only as mechanical obstacles
to labor. If the biood-tumor is lai^e enough to constitute an
obstruction to the escape of the child, its walls must be incised
and its contents be turned out, and if hemorrhage follows, it must
be checked by a firm tampon, preferably of iodoform gauze, in
the cavity of the tumor.

fjtUitsi'i'c cicatrices in the vagina from syphilitic, malignant,
or other ulceration, or from former injuries, may be stretched
sufficiently by hydrostatic dilators or may be severed by multiple
the atmlication of forceps if the head is

r prese

i to th<

ANOMALIES IN THE FORCES OF LABOR.

presenting ; but they may be too dense and extensive to yield
to these measures, and a Cesarean section may be required.

Unruptured Hymen. — An unruptured hymen is not neces-
sarily a bar to conception. There are a number of cases on
record in which a persistent hymen with a small orifice has ob-
structed to some degree the escape of the child's head in labor.
In two cases under the author's notice the advance of the pre-
senting part ruptured tiie hymeneal membrane without difficulty,
but it has been found necessary by others to incise it. '

Atresia of the Vagina. — This anomaly of development has its
scat usually at the upper third of the canal, where the vagina may
be contracted to a narrow tract barely admitting the uterine probe,
or the canal may be obstructed by an annular membrane like the
hymen. Although Cesarean section has been done for this con-
dition, the majority of cases on record have not required it. The
advance of the presenting part has dilated the narrowed vaginal
canal with little more difficulty than it experiences in dilating the
cervical canal. At the worst, the obstruction should be over-
come by digital, instrumental, or hydrostatic dilatation. In com-
plete or almost complete acquired atresia of the lower portion of
the vagina, in which insemination has taken place by way of a
dilated urethra and a vesicovaginal fistula, the imperforate
portion of the vagina may be opened by a transverse incision, the
rectum and bladder being guarded by a finger in the one and a
sound in the other.

Anus Vaginalis or Vestibularis. — This condition may com-
plicate labor by the accumulation of feces in the rectum, due to
the unnatural position of the anus (Fig. 355). In one case in
which this anomaly was associated with partial atresia of the
vulvar orifice it was necessary to cut the perineal structures up-
ward from the rectum toward the pubis, in order to permit the
escape of the child's head.

Cystic and Solid Tumors of the V/tgina and Vulva, Edema,
Suppuration, and Gangrene. — In the case of solid tumors ex-
cision may be necessary, by transfixing the pedicle if they have
one. and ligating it to prevent hemorrhage, or by an incision of
the vaginal wall over them and their enucleation, followed by
the immediate extraction of the child, and the control of hemor-
rhage by the needle and thread or by direct pressure. In the
case of large cystic tumors a puncture is sufficient to remove the
obstruction. Guder * collected 60 cases of vaginal tumors compli-

' .\h1fcld. "Zeitschrift f. GeburUhilire ond G^nSkologic." Bd. xil. p. l6o;
ibid., Bd. liv, p. I4.

' " Uebcr rieschwfllstc dcr Vagioii als Schwangenchan und Gebunskampli-

VatJonen," ■' Diss.4nBug.," Bern, 1889.

490

THE PA THOLOGY OF LABOR.

cadng labor — 23 cysts and echinococcous saca ; 18 fibroids,

fibromyoniata, and polypi ; 14 carcinomata, i sarcoma, and 4
hematomata. Delivery was accomplished by the following
diverse methods; Spontaneously, 14; by forceps, 18; by ver-
sion and extraction, 1 ; by traction on the feet. 1 ; by removal
or puncture of the tumor, 16 ; by Cesarean section, 7 ; by iji-
duction of premature labor and craniotomy, 3; by premature labor,
3 ; by laparo-elytrotomy, 1 ; by craniotomy I ; by pushing back
the tumor and extracting the child past it, 2. Among the
mothers there were 15 deaths; among the children. 13. In 1 1
of the mothers and in 22 of the children the result was not
reported.

Edema of the vulva may be the result of kidney insufficiency

(nutlior's

or of pressure in a prolonged labor. The increased bulk of the
dropsical labia may interfere with the escape of the presenting
part, or, what is more likely, the edematous tissues lose their
elasticity, obstruct labor by their rigidit\'. and arc prone to deep
tears at the time of birth and to gangrene afterward. Punctures
or incisions in the labia ma\' be necessary to escape more serious
injury, but it is well to avoid them if possible, for they are apt to
be followed by infection and gangrene.

An abscess of Bartholin's gland is seldom large enough to
retard labor, though it has done so (Muller), but it is likely to
l-troublc afterward. It should be opened freely in the early

ANOMALIES IN THE FORCES OF £ifSWf

491

part of the first stage of labor, curetted, swabbed out with car-
bolic acid and glycerin, and packed with iodoform gauze.

Gangrene of the vulva is very rare before the termination of
labor. Should it exist, it might determine an operator in favor
of Cesarean section in a doubtful case, on account of the rigidity
of the vulvar tissues, the certainty of laceration, and the likeli-
hood of grave infection.

ii?tlargid CaruncidtF Myrttformfs and Varicose Veins. — These
tumors do not possess sufficient bulk, as a rule, seriously to ob-
struct the last stage of labor. They may. however, be so bruised
by the passage of the head as to slough afterward, or the veins in
them may be ruptured, giving rise to subcutaneous or frank bleed-
ing of an alarming character.

Vaginismus may be overcome by an anesthetic. Congenital
narrowness of the vagina and
vulva is usually overcome by
the advance of tlie presenting
part, though often at the ex-
pense of vaginal and perineal
lacerations. It may be neces-
sary to resort to hydrostatic
dilatation, or even, in rare in-
stances, to Diihrssen's plan of
multiple incisions. In the case
of extreme narrowness of the
vulva there may be a central tear
of the perineum, through which
the presenting part begins to
emerge. To avoid a rectal tear
in such a case the perineum
should be cut from the anterior
border of the perforation to the posterior commissure of the vulva
(Fig- 357).

Rigidity of the ti.ssues in the cervix, the vaginal wall, and at
the outlet occasions delay in the majority of all primiparse, but
especially in the case of elderly primipara: — those> over thirty
years of age. Eckhard found the infantile mortality in such cases
to be 19.81 per cent., the maternal mortality to be three times as
great as in younger primipara; ; and the necessity- for operative
interference increases steadily with the age of the primipara; until,
in those past forty, almost two-thirds are delivered by some
operative procedure, usually forceps. Craniotomy should be
done if the child is dead. Version is the least successful opera-
tion in these cases.

Dlftptacements of the Uterus. — The uterus in labor may be

J57. — Cenlral tear
, Willi contracted vi
ficF (Ribemonl-DusBignes).

492

THE PATHOLOGY OF LABOR.

displaced forward ; to cither side ; downward ; or backward, by
the so-called " sacculation " of the womb. It may be twisted on
its pedicle, the cervix, or it may form part of the contents of a
hernial sac in inguinal or ventral hernise.

Anterior Displacement of the Uterus in Labor ; Pendulous
Belly. — This is a common anomaly in labor, seen to some degree
in all cases of obstructed labor, as in deformed pelvis, and in all
cases in which the length of the abdominal cavity is decreased,
as in kyphosis. A peculiar example of forward displacement is
seen in those rare instances of hernia of the parturient womb
between the recti muscles or to one side of the median line dur-
ing the second stage of labor (Fig. 358). The pregnant womb

FiB- 358.-

ia of ihe gravid womb (hrougli lh<

U (Dickinson).

may fall forward also into an umbilical hernia or into a ventral
hernia following celiotomy.

The removal of the obstruction to labor in the first class of
cases will ordinarily obviate the anterior displacement. If the
displacement depends not upon obstruction, but upon flaccid
abdominal walls, the application of an abdominal binder surely
corrects the anteversion. In ca.ses of hernia of the Uterus through
the anterior abdominal wall, artificial delivery witli forceps or by
version may be necessary ; when the uterus is evacuated, it can
easily be returned into the abdominal cavity. A tight abdominal
binder and the diminution of intra-abdominal pressure after de-
livery will promote the approximation of the separated recti

t musi

ANOMALIES I.W THE FORCES OF LABOR.

493

muscles. In inguinal hernia the pregnant womb in the hernial
sac is usually unicom or bicom (Fig. 359). Delivery may be
effected by version, and this may be followed by a reduction of
the hernia, but it is best to lay open the sac, incise the womb,
extract its contents, and then amputate it. Adams ' has collected
ten cases of inguinal hernia of the gravid womb, including Dorin-
gius's. which he calls "crural." In eight Cesarean secdon was
done ; in one the delivery was spontaneous.

Labor Complicated by tt Fonmr Operation to Suspend or Fix
the Womb Anteriorly. — The Tjumber of operations performed for
posterior displacement of the uterus on women of child-bearing
age has become so large of recent years that ample opportunity
has been afforded to judge of the influence of anterior fixation

Fig. 359 -Inguinal hernia containing a gravid womb (Wiockel)-

and suspension of the uterus on pregnancy and childbirth. Dor-
land - has collected the statistics of 179 pregnancies following
operadons for ventrosuspension, ventrofixation, and vaginal fixa-
tion. It appears from these statistics that, the firmer the womb
is fixed and the lower the fundus is fastened, the more certainly
will there be serious disturbances in pregnancy and dangerous
complications in labor. Thus, abortion occurred in 14 per
cent of the ventrosuspensions and in 27 per cent, of the vaginal
fixations. In 12.29 F*'' c^nt- of ^11 the cases there was dys-
tocia, requiring in three instances Cesarean section. The com-

ims, "Heroin of the Pregnint Ulenis,"

. Jour. Obsteli

■' University Med. Mag.," Uec., 18;

494 THE PA TIIOL OG Y OF LABOR.

plications noted in labor were : inertia uteri, transverse position
of the child, abnormal positions of the head, cervical rigidity,
uterine rupture, placental anomalies, postpartum and puerperal
hemorrhages, and a mechanical obstruction in labor from the
thick anterior wall of the uterus, held firmly down over the pelvic
inlet, the distention of the uterus in pregnancy having been accom-
plished by the expansion mainly of the posterior uterine wall.
Pregnancy was seriously disturbed in 8.37 per cent, of the cases,
not including those in which abortion occurred, by pain and trac-
tion at the site of the incision, dysuria, and excessive nausea and
vomiting.

A sure indication of the difficulty to be expected in labor is
afforded by the behavior of the fundus and cervix of the womb in
pregnancy. If the latter remains fixed over the pelvic inlet and
the former is steadily drawn upward and backward until it reaches
the promontory of the sacrum or actually ascends above it, the
labor will be so seriously complicated in all probability that,
in the hands of an expert abdominal surgeon, the best results
may be obtained in the future by opening the abdomen and sever-
ing the adhesions between the fundus uteri and the abdominal
wall. If version is demanded in labor at teriti, great care must be
exercised not to rupture the overstretched posterior uterine wall.

The best preventive treatment of difficulty in pregnancy and
labor after the operative treatment for posterior displacement is
the choice of the appropriate operation and its proper perform-
ance. Vaginal fixation should not be selected. Shortening of
the round ligaments has not yet given rise to any difficulty in
subsequent pregnancies and labors, nor has ventrosuspension,
properly performed. If the operator uses fine silk and includes
only a portion of the rectus muscle with the peritoneum in the
abdominal portion of the stitch, the artificial suspensory ligament
is so flexible and stretches so easily that no difficulty need be
apprehended if the patient conceive. In not one of the numer-
ous women operated upon by the author has there been the
slightest complication traceable to the operation in pregnancy and
labor.

Lateral Displacement. — A tilting of the uterus to the right
side is^ a physiological occurrence in pregnant and parturient
women. The lateral inclination is sometimes exaggerated to
such a degree that a great part of the expulsive force is lost by
the propulsion of the presenting part against the lateral wall of
the pelvis. The displacement may be corrected by turning the
woman on the side — usually the riixht — toward which the fundus
uteri is inclined, and placing under her flank a rolled blanket or
a pillow.

! gravi

ANOMALIES IN THE FORCES OF LABOR.

495

Sacculation of the Uterus. — A backward displacement of the
gravid womb in rare cases goes on to full development by what
called "posterior sacculation." the distention of the uterus to
accommodate the full-grown fetus being accomplished by stretch-
ing the anterior uterine wall, the posterior wall and tlie fundus
remaining fixed within the pelvis
(Fig. 362). In these cases the
cervix is liigh above the pelvic
inlet and is pressed close against
the anterior abdominal wall, llu
posterior vaginal wall bulges I'U'.
ward and downward, and Iclai
parts can be felt through it witli
a distinctness that suggests ab-
dominal pregnancy. Cesarean
section has in one instance at
least been performed on account
of this anomaly, but a study of
recorded cases shows it to be
unnecessary. By the artificial
dilatation of the cervical canal
and the performance of podalic
version, delivery may be effected
without difficulty.

Partial Prolapse iviih Hyper-
trophic Elongation of the Cenii.r.
— It is impossible for pregnancy
to proceed to term with com-
plete prolapse of the womb,
although the size of the uterine

tumor projecting from the vulva in some cases has given rise to
a belief in this possibility (Fig. 360). A careful examination has
always shown the major portion of the uterine body to be within
the pelvic and abdominal cavities. Commonly, the fundus is at a
normal level, and the descent of the cervix has been accomplished
by stretching the lower uterine segment and by hypertrophic
elongation of the cervix itself When the contraction of the
uterine muscle begins in labor, a partial prolapse of the womb is
usually spontaneously corrected by the retraction of the cervix
within the vagina. This the author has seen in several instances.
In exceptional cases, however, — usually on account of a rigid
cervix, — the prolapse becomes aggravated or suddenly makes its
appearance, and the cervical tissues, growing edematous and be-
coming enormously swollen, con.stitute. by their bulk and in-
creased rigidity, a serious obstruction to the delivery of the child.

Fig. 360.-

n Inljor (Wagtiet).

496

THE PATHOLOGY OF LABOR.

Kg. 361.— Prolnpse of a doiibli

pregnBiil vroman (Maygiier).

This difficulty was overcome in an ingenious manner in a case
reported by Faivre.^ The woman was placed in the dorsal posi-

" Nouvellcs Archives d'Obstitri

ANOMALIES IN THE FORCES OF LABOR.

tion across the bed, a forceps was applied to the child's head, and
AW assistant, standing astride the woman's body, hooked his fingers

Fig- 36s. — Displacement of the

into the cervix and pulled upward to counteract the traction of
the forceps upon the child's head and the Incarcerated cervical

498 THE PATHOLOGY OF LABOR.

tissues. It might be necessary in such a case to enlarge the
cervical canal by radiating incisions. The hemorrhage following
might be controlled temporarily by clamping sutures over the
wounded surfaces without uniting them (Figs. 363, 364).

Displacement of the Cervix. — It is not uncommon, in prim-
iparae with a narrow cervical canal, for the cervix to be displaced
backward, so that the external os, almost inaccessible to the ex-
amining finger, points directly backward or even backward and
upward. The anterior lower uterine segment is much distended
by the presenting part and occupies the whole vaginal vault.
The expulsive force in labor is exerted against the lower uterine
segment, and the cervical canal remains undilated. The difficulty
may be overcome by applying an abdominal binder and by hook-
ing the cervix forward with the finger during two or three pains

(Fig. 365)-

Tumors of the Qenital Canal. — Carcinoma of tJte Cervix. — In a
large proportion of cases cancer of the cervix interrupts ges-
tation at various stages, but in a certain percentage (sixty-six,
according to Miillcr) the pregnancy goes to term. If the disease
is not too far advanced ; if it is confined to one lip of the cervix,
and that the anterior ; and if there is not too much cicatricial
infiltration around its periphery and up the cervical walls, the
labor may be terminated spontaneously, but this is rather the ex-
ception. The performance of Cesarean section is commonly the
proper treatment for labor obstructed by carcinoma of the cervix,
and this operation should be selected if there is good reason to
doubt the possibility of spontaneous or artificially assisted delivery
by the natural passage-way. The woman's life is surely doomed
in the near future, and the child at any rate should be saved,
even at considerable risk to the mother. It may be desirable to
operate before the fetus has reached maturity, if the disease is
making such rapid progress that the woman is likely to die before
the natural end of pregnancy.

Fibromata. — Fibroids of the uterus and cervix low enough in
situation to become incarcerated in the pelvis are likely to con-
stitute insuperable obstructions in labor, besides complicating
parturition by favoring abnormal positions of the child, by pre-
disposing to adherence of the placenta, to prolapse of the ex-
tremities and cord, and to hemorrhage during and after labor.
If the tumor grows on the anterior wall of the uterus, the first
few labor-pains and the contraction of the longitudinal fibers of
the cervix may dislodge it above the pelvic brim, though it had
been impossible to do this before by manipulation. The author
has seen one such case. It is also possible for tumors on the
anterior wall of the cervix to be pushed out of the vulva in front

ANOMALIES IN THE FORCES OF LABOR. 499

of the presenting part, thus making room for the escape of tlie
latter. If, however, the tumor is situated laterally or posteriorly,
its artificial displacement upward into the abdominal cavity, so
that the child may escape past it, is often impracticable (Fig.
366), On the contrary, the attempt at descent of the presenting
part in labor must fix it more firmly in the pelvic cavity.^ In
this case, if attempts under anesthesia to dislodge the tumor and
to push it above the pelvic brim fail, a Porro- Cesarean operation
should be performed, even though the tumor is not of so great a

Large fibroid blocking Ihe [leliis ^SpiegelbeIX).

size as absolutely to prevent the delivery of the child. The
physician must consider the effect upon it, owing to its low
vitality, of the pressure to which it will be subjected by dragging
the child past it (Fig. 367). Sloughing, gangrene, and fatal in-
fection are likely to follow. This was the history of the case

' It is barely pos^il.le ihal a tumot low down on ihe poslrrior wnU of the cervis,
the tnost unfayorabic of all [weiltons, may he suddenly tlevaled afler many hours of
labor, and thus allow a spontaneous delivery -, but this event is not to be counted on

THE PATHOLOGY OF LABOR.

SOO

illustrated in figure 367, communicated to the author by Dr. J. P.
Simpson, of South Carolina. If the fibroid is submucous and
grows from the cervix, it may be enucleated when labor begins.
The bed of the tumor should be packed with gauze after labor.*
It is, unfortunately, a common error to overlook a fibroid
tumor obstructing the pelvis in labor, or to mistake it for the
fetal head. The woman is allowed to die of ruptured uterus,
exhaustion, or hemorrhage, while the physician is waiting for the
descent of the presenting part, or is endeavoring to apply the
forceps to what he takes to be the head. Ordinary care and
a little experience in making obstetrical examinations should
guard a practitioner against such an c^TL-ijinu,'' mistake.

Tlu- propiosis of labor complicated by a fibroid tumor de-
pends upon the early recognition of the growth and upon the
treatment. In general practice the results have hitherto been
bad. Nauss found a maternal mortality of 54 per cent, among
225 women and an infantile mortality of 57 per cent, in 1 17
cases. Siisserott found in 147 cases a maternal mortality of 50
per cent, and an infantile mortality of 66 per cent.'

■ Sutugin is an enthusiastic adeocate of Paginal oprralions for all cases of fibroid*
impacted in the small pelvis. For inlramucat tutnora the cervix is split ontil the
iQtDOf' is reached. For subserous tumors the vagina] tbuII is opened. Nine such
operations mi faria ait reported with only one death (" Jahresb, a, d. Forisch. ■. d.
~ ' ' ;e der GcbuiWb.," etc., vol, v. p, 175). ' Sulugio, Im. nV.

ANOMALIES IN THE FORCES OF LABOR.

SOI

In Lefour's statistics of 300 cases of fibroids complicating
labor, the mortality of delivery by the natural passage was 35 to

55 per cent, for the mothers, 77 per cent, for the children.'

A fibroid tumor may prolapse into the pelvis after the birth
of the child and prevent the delivery of the placenta.

Polypi. — Polypoid tumors obstructing labor usually spring
from the cervical canal or the anterior lip of the cervix, and are
mucous in character. They may. however, be fibromyomatous,

(aulhor's

— Subperiloneal fibromau. The growth aUachcd to Ihc lower uieriiiE
impacted ID the pelvis, insuperably □bsltucllng labor. Celiohyslereclo-
n tecDvered, although she hnd been id labor four days; child dead

fibrous, or sarcomatous, and may have a situation high in the uter-
ine cavity or in its wall. They may increase very markedly in size
during pregnancy. Their pedicle is usually small, and in the case
of cervical polypi their removal is easy. The operation should
be postponed, however, until the woman falls into labor, for any
operative interference in this region would very likely interrupt
gestation. When the dilatation of the os begins, the pedicle may
be transfixed and ligated and the tumor be cut away. Even if these

> Phillips. " Briliah Med. Jour," 1888, j. p. 331.

502 THE PATHOLOGY OF LABOR.

growths are not sufficient in bulk to obstruct parturition me-
chanically, they have been known to give rise to profuse hemor-
rhage in the first few days of the puerperium, and llieir removal
is desirable, therefore, even though they be small in size. In the
case of fibro myomatous polypi of the uterine body, the tumor
has on rare occasions been torn from its pedicle during labor and
expelled in front of the child.

Tumors of NelghborlRK Organs. — Ovarian Cysts. — An ovarian
cyst is a rare complication in labor. In 17,832 births in the
Berlin Frauenklinik, an ovarian cyst was found only five times.
The number of abortions in pregnancies complicated by ovarian
cy.sts is somewhat larger than conmion, but still a large pro-
portion of these cases proceed to term. Of 331 pregnancies

Fig. 369. — Dermoid Qy:

complicated by the presence of ovarian cysts, there was prema-
ture interruption in 55 (Remy). If the cyst is discovered during
pregnancy, its removal should be attempted. Ovariotomy during
gestation is not necessarily a difficult or dangerous operation,
nor does it, as a rule, interrupt pregnancy.^ If the tumor is
firsl discovered after the woman has fallen into labor, and if it has
become displaced downward into the pelvic cavity and is incar-
cerated, resisting all efforts tn displace it upward, even under
anesthesia, its puncture through the vagina! vault, after a

' Dsime has collected sWlislic? of 1}$ operBliirs wilh a mnrlality of 5.9 |>er
cent. Pregnane}' is inlertiipled by llie operatron iu about 10 per cenL of cues
(Fluscblen, " Zeitsclirifl (. GeburtsliUlfe," x>ii, p, 49).

ANOMALIES IN THE FORCES OF LABOR. 503

thorough cleansing of the vaginal mucous membrane and with
a thoroughly aseptic technic, is said to give the best results. It
is a matter for serious consideration, however, whether Cesarean
section followed by the removal of the tumor is not better. It is
the author's conviction that it is. ^ By this plan many dangers in
the puerperium are escaped. Twisted pedicle, intracystic bleed-
ing and shock, occlusion of the bowels, rupture of the cyst, sup-
puration of the cyst-contents, and consequent peritonitis are all
surely avoided. A number of cases treated thus should give a
better mortality record than has hitherto been secured. In
Heiberg's statistics of 271 cases there was a maternal mortality
in pregnancy of more than 25 per cent, and a fetal mortality of
more than 66 per cent. In deliveries by forceps without punc-
ture of the cyst the maternal death-rate has been 50 per cent. ;
with puncture, almost as great ; and after version without punc-
ture, more than 50 per cent. Flaischlen recommends the vaginal
puncture, or, if necessary, a vaginal incision and thorough evac-
uation of the tumor, then the delivery of the child, and on the
following day at the latest an abdominal section for the removal
of the tumor. This procedure does not seem to me so good
a plan as the coincident Cesarean section and ovariectomy.
Should the physician prefer vaginal puncture, — which requires,
of course, no special surgical skill, — he should remember that if
the tumor be densely adherent, possess thick walls, and possibly
be a dermoid cyst, puncture through the vaginal vault is likely
to be followed by gangrene of the tumor-contents and walls and
by general infection. The infection of the tumor necessitates a
hurried abdominal section in the puerperium, with the patient in a
bad condition to endure it. Moreover, if the cyst is multilocular,
it may be impossible to reduce its size sufficiently by vaginal punc-
ture to permit the delivery of a living infant. The author has
experienced both the disadvantages of this plan of treatment.

Spontaneous delivery in spite of an ovarian cyst incarcerated
in the pelvis has been noted after the cyst ruptured, after it had
been spontaneously dislodged upward above the pelvic brim, or
had perforated the vaginal vault or the rectum. As an ovarian
cyst must be impacted in the pelvis to obstruct the delivery of
the child, it is easily understood that there is more difficulty and
danger in labor from a small than from a large tumor (Fig. 370).
After the child is born, a cyst that had before been above the brim
may descend into the pelvis and obstruct the delivery of the
placenta.

Vaginal Enterocele. — Vaginal hernia is a very rare obstruction

* I have performed Cesarean section twice for large dermoids impacted in the
pelvis obstructing labor, with a successful result for both mother and child.

504 THE FA TilOLQG Y OF LABOR.

labor. The author has been able to collect but twenty-seven cases
from medical literature. Of these, only two were anterior entero-
celes ; Che others wen; lateral and posterior. The distention of the
hernial sac in labor is apt to become excessive, and to threaten
its rupture with protrusion of intestinal loops. An effort should
be made to reduce the hernia as soon as it is discovered. The
reduction may be facilitated by placing the woman in tlie knee-
breast posture and by inserting the whole hand into the vagina.
If this treatment is instituted in pregnancy, it should be followed
by the insertion of a large tampon or a globe pessary and by pro-
longed rest in bed : in labor the presenting part should imme-
diately be brought down past the hernial ring. If there are
adhesions about the latter, preventing the reduction of the hernia.

the tumor should be supported and held to one side by assistants
while the child is artificially extracted by forceps or after version.
Should the sac rupture and the intestines protrude, the child
must be delivered hastily, the Intestines be cleansed thoroughly
and replaced, and the opening be sewed up. In the case of a
very targe irreducible vaginal hernia, Cesarean section would
be preferable in a labor at term.

Other growths or tumors in the pelvic inlet and cavity ob-
structing labor have been fibrocystic tumors of the ovarian liga-
ment, requiring an abdominal section ; fibroma of the ovary ;
sarcoma of the ovar>' ; a displaced adherent kidney at the pelvic
inlet, necessitating version and forcible e.vtraction •} hydatid cysts

' Runge rrporU four c«5e* (" Arehiv f. Gyn.," xli, p. 99). The writer luw had
ODC. Albera-Schoenberi! reports nncxhcr in which (he uterus ruptured ("Ccntmlblatt
f-Gyn.," Dec. 1. i8im)-

ANOMALIES IN THE FORCES OF LABOR. $0$

of the pelvis, demanding Cesarean section ; a displaced and en-
larged spleen ; masses of exudate, and an aneurysm of the gluteal
artery.

A cystocele and a rectocele should be replaced if they pro-
trude to a great extent in front of the head, and should be held
back until a forceps is applied and the head is pulled past them
(Fig. 371). Version and extraction have occasionally been
found necessary. Large fecal masses in the rectum must be re-
moved by an enema or must be dug out. ^ Calculi in the blad-
der should, if possible, be discovered and removed by the urethra
or by vaginal lithotomy before the second stage of labor. They
may become nipped between the head and the pubic bones, and
may pinch a hole through the anterior vaginal wall and bladder
if they are overlooked or neglected. ^ The diagnosis of vesical
calculus in the parturient woman appears to be somewhat diffi-
cult : it has been taken for a pelvic exostosis or some other pelvic
tumor, and in one case at least Cesarean section was performed
on account of this mistake. Fortunately, vesical calculus in the
female is rare. In 10,000 women examined by Winckel in fifteen
years, it was found only once.

The following conditions in and about the rectum may pre-
sent mechanical obstacles to delivery : Cancer, anus vestibularis
or vaginalis, foreign bodies, contraction of the levator ani mus-
cles, benignant tumors, such as cysts of the rectum, ovarian cysts
which have perforated the rectum, and retrorectal dermoid cysts.
Each of these conditions must be treated according to the indi-
vidual indications. Incisions in the perineum may be required,
foreign bodies must be removed, resisting muscles on the pelvic
floor may be overcome by an anesthetic and by the application
of forceps, and cystic tumors, should be punctured or removed
after ligation of their pedicles. Cancer of the rectum may demand
the p)erformance of Cesarean section by reason of the size of the
tumor and the cicatricial infiltration of the birth-canal, as in
Freund's case.

8. Obstruction in Labor on the Part of the Fetus. — Over-
growth of the Fetus. — Excessive overgrowth of the fetus is rare.
The writer searched the records of more than 1000 children in
the Maternity Hospital of Philadelphia before he found one that
weighed more than 12 pounds ; weights, however, of 15, 16, 18,

* Corradi tells of a case in which seven pounds of hardened feces were removed
before the woman was delivered.

' Kotschurowa has reported a case in which labor lasted three days. At the
end of that time a gangrenous tumor protruded from the vulva, which tumor proved
to be the bladder and anterior vaginal wall. The midwife in attendance perforated
the tumor with her finger, whereupon a calculus eighty- five grains in weight was dis-
charged (** Jahresbcricht ii. d. Fortschr. a. d. Gebiete der Geburtsh.," etc., vi, 225).

506 THE PATHOLOQ Y OF LABOR.

2i}4, and zS^ pounds have been recorded. The causes of over-
growth in the fetus are prolongation of pregnancy, oversize and
advanced age of one or both parents, and multiparity. Rarely, it
may be inexplicable. The first named is, in the writer's experi-
ence, the most common cause. In six per cent, of women preg-
nancy may be expected to be prolonged beyond the three-
hundredth day, and for every day that the fetus is retained in the
womb beyond the usual time there is an increase in its size and

weight above the normal. So much difficulty and danger may
be experienced from this cause that it is a good rule in practice
to allow no woman to exceed the normal duration of pregnancy
by more than two weeks. By inducing labor at that lime one
wi^l occasionally interfere unnecessarily, but he will often avoid
complications and difficulties of the most serious nature.

Oversize and advanced age of one or both parents may be a
cause of overgrowth in the Ictus — the latter usually because it
predisposes to a prolongation of pregnancy. It is commonly

ANOMALIES JN THE FORCES OF LABOR.

SO7

asserted that the size of children increases in successive pregnan-
cies up to the fourth or fifth, and then remains stationary or even
decreases ; but there are important exceptions to this rule. The
writer has seen the tenth child vastly exceed in size the nine pre-
ceding ; it weighed 15 pounds, and it was necessary to deliver
it by Cesarean section. The other children had been bom natu-
rally through a flat pelvis with a conjugate diameter of nine centi-

Fig. 376. — Craniopagus.

Fig, 377. — Iscbiopagus parasiticus.

meters. The increase in size of successive children must be
borne in mind in cases of contracted pelvis. The first two or
three infants may be delivered spontaneously, but the larger size
of the fourth or fifth may make natural delivery impossible.'

' I^hmiinn in 713 labon Ihrciugb I98 conlractcd pelves found increasing diffi-
culty in delivery wilh each succeeding lal>or. In iirsi lalxira 50 per cent, ended spon-
Uneonsty 1 in second, 43. S ; in fourth, 38.4; in tiftli,33(^ ; «nd in labors after the fifth
only 9.S per cent. (" Diss. Inaug.," Berlin, 1891).

S08 THE PATHOLOGY OF LABOR.

Overgrowth of the fetus is the most difficult condition in
obstetric practice to diagnosticate with precision. A careful jjal-
pation of the head and body and an attempt to push the former
into the pelvic inlet may give one an approximate idea of the

Fig. 380. — Prosopolhorncopagm, Fig. 381

Fig. 38 1. — Janiceps.

relative size of fetal body and pelvic canal, but as a matter of
fact the large size of the fetus is usually discovered in practice
only after prolonged delay when attempts at artificial deliverj%
especially by version, have failed. By this time the fetus is com-

ANOMALIES IN THE FORCES OF LABOR.

sog

monly dead, and should be delivered by embryotomy. But the
practitioner must be on his guard against futile attempts to de-
liver an infant loo large, even when mutilated, to pass through
the pelvis. The writer has seen, in consultation practice, several
maternal deaths due to this cause.

Premature Ossification of Cramum ; Wonnian Bones ;^ Large
Heeiiis : Malformations and Tumors of the Fetus. — No single rule

Fig. 38J. — Dicepllfllus : neilhcr bead ciigjgeii.

of treatment can be laid down for the management of these cases.
Forceps, version, or some form of embryotomy is usually de-
manded. Spontaneous labor, however, is possible even in cases
of monstrous bulk in which delivery through the birth-canal

' Dr. GfBce Pcckam
three sliLl- births, allribulei

the Bmaller fonlnntl. and

" New York Med. Record,"' April 14, iSfiS) has reported
in each malance to the developmenl of Wormiin botiei in
1 the consequent interfetence with overlapping of the
This obsenation has not yet been verified by others.

5IO THE PATHOLOGY OF LABOR.

fig. 384.— Hydreneephalocelc (snietiot).

I'lg' jSS —■''"" I IrnloniH obstiucling labor.

ANOMALIES IN TUB. FORCES OF tABOA S 1 1

would seem out of the question. Thus, in double monsters

joined loosely by the front or back (xiphopagus, the Siamese
twins ; pygopagus. the Hungarian sisters), one child will be bom

I^>e- j8&- — Sacral teratoniB.

by the head, the other afterward by the breech, or vice versa. In
dicephali one head may be pressed into the neck of the other or
may re.st upon the iliac bone of the mother until the first head
makes its escape from the vulva. Even in thoracopagus, the

commonest double monstrosity, in which two trunks are inti-
mately joined front to front, spontaneous labor is possible by the
mechanism shown in figures 39oand 391. On the other hand the

THE PATHOLOGY OF LABOR.

greatest difficulty may be encountered in labor, and the most
serious operation may be demanded to deliver the woman.*

Fetal tumors obstructing delivery may be hydrencephaloceles.
lymph angiomata, myxomata, sacral teratomata. Cystic tumors

ANOMALIES IN THE FOftCES OF LABOR. 513

should be punctured. Solid tumors may call for version or for
embryotomy. Craniotomy may be required in monstrous en-
largement of the cephalic extremity, as in syncephalus or in
diprosopus. Decapitation may be necessary in duplicity of the
cephalic extremity, as in dicephalus or in thoracopagus. In
Reina's case of tricephalus the first head was perforated and then
amputated, the second was perforated, crushed, and amputated,
and the third was amputated.

Diseases and Death of the Fetus. — All diseases of the fetus
that increase its bulk may constitute thereby an obstruction in
labor. Cystic tumors, effusions in the serous cavities, anasarca, an
enlarged liver, polycystic disease of the kidneys,^ and distended
bladder from atresia of the urethra ^ are examples. IJquid
accumulations should be evacuated by puncture or by incisions.

Hydrocephaltis is the most important of the diseases increasing
fetal bulk. It is not very rare,* is often overlooked, and is a
frequent cause of ruptured uterus. The diagnosis may be made
by a vaginal examination, by abdominal palpation, and by a com-
bined examination, or, if necessary, by anesthetizing the woman,
introducing the whole hand into the vagina, and thoroughly
palpating the enlarged head resting above the pelvic brim. The
gaping fontanel, the great width of the sutures, the fluctua-
tion to be felt perhaps in these regions, the large size of the
head appreciated by bimanual examination, and possibly the ab-
normal mobility of the cranial bones, and in some cases their
extreme tenuity, indicate the condition. Hydrocephalus is very
often overlooked in practice as the result usually of a careless,
superficial examination. A painstaking and methodical investi-
gation of a suspected case should obviate this error. There are
cases, however, in which there is no increased width of the
sutures, no enlargement of the fontanels, and such slight en-
largement of the head that it can not be appreciated ; and yet the
fluid contents of the cranium prevent compression of the skull
and make the engagement of the head impossible. The writer
has seen one such case (see Fig. 392). Hydrocephalus should
always be suspected if the head in labor remains above the brim,
although the pelvis is normal in size and no good reason can be
found for the failure of engagement.

1 Fussell, **Med. News," Philadelphia, 1891, p. 40.

' Schwyzer (** Archiv f. Gyn.," Bd. xllii) has collected 13 cases of dilatation of
the fetal bladder from atresia of the urethra, stenosis of the urethra, and obstruction
of the urethra by a valve-like formation of mucous membrane. MUller reports a case
and quotes another (** Archiv f. Gyn." Bd. xlvii, H. i).

• Schuchard found it sixteen times in 12,055 births; Lachapelle and Dug6s,
fifteen times in 43,555 ; Mcrriman, once in 900. In 159 cases there were 38
maternal deaths, 20 of which were from rupture of the uterus.

514 THE PATHOLOGY OF LABOR.

The treatment of labor obstructed by hydrocephalus is punc-
ture of the cranium with a perforator and evacuation of its fluid
contents. A chiid with this disease deserves no consideration.

After the reduction in the size of the head the tabor may be left
to the natural forces. If these prove insufficient, a cranioclast
may be fastened to the skull and the child be extracted artificially.
A cardinal rule in the treatment of these cases is to avoid at-
tempts to deliver with forceps — a common error in practice, and
one that has cnst many a woman her life from ruptured uterus.

% Kig. 3gi. — Hydrocenlittlos; vi

nioilerBle dislention of the cranium, ;
sufficient to prove lu insuperable i
itacle in latxic.

^'ig- 393— Ilydrocephalua
collsclioii of fluid {author's collcclion :
specimen presented by I>r. Alex. Fulton).

from deep tears when the instrument .slips, as it will, and from
extensive sloughs after delivery.

If the pelvic extremity of the hydrocephalic fetus presents, —
as it does in almost a third of all cases, — and if the head remains
inaccessible above the superior strait, so that it can not easily be
punctured, the spina! canal may be opened, a catheter be passed
through it into the cranial cavity (Van Huevel's method), and
the fluid thus be evacuated (Fig. 394). Usually, however, there
is no special difficulty or danger in the dehvery of the after-

ANOMALIES JW THE FORCES OF LABOR.

SIS

coining head of a hydrocephalic infant. The force required for
its extraction not infrequently ruptures the walls of the ventricles
and converts the case into one of external hydrocephalus, or
[wssibly drives the fluid out of the foramen magnum into the
tissues of the neck and back, so reducing the bulk of the head
as to permit its extraction. At any rate, the condition can

scarcely escape tlie notice of the medical attendant, and ad
nosis is made before the lower uterine segment is dangeroLsIy
stretched or ruptured.

The difficulty in the delivery of a hydrocephalic fetus is not in
direct proportion to the quantitj' of fluid in the ventricles and
the size of the head. In cases of extreme distention, the cranial

Sl6 THE PATHOLOGY OF LABOR.

vault is likely to rupture, while in moderate grades of hydro-
cephalus the quantity of brain -substance surrounding the ven-
tricles and the strength of the brain-membranes forbid this
means of spontaneous delivery,

Mai presentations and faulty positions include shoulder, face,
brow, deviated vertex, and compound presentations. All but

Fig. 39S- — Compound presenlalion : head and hand. Itraun'l section uf a
multipara wbo commllln! suicide by hanging in ihe list moDlb of pnzgnancjr: a,
Veuous sinuses -, *, uteroTcsical refleclion of peritoneum; r, symphysis pubis; d.
bladder ; r, vagina ; f, hxS. lumbar vertebra ; g, promiiiiiary u( sacrum ; h, rccluin ;
I, cervii ; j, pouch of Douglas.

the last are considered elsewhere. By compound presentation
is meant the presentation of two or more parte at the same time,
as a head and a hand, a head and a foot, a hand and 3 foot,
nuchal position of the arm, or the head and all four extremities.
A compound presentation is m'-x with ahont once in 350

AXOMALIES IN THE FORCES OF LABOR. 517

labors. It is usually a head and a hand. The following table is
furnished by Pernice from 2891 births in the clinic at Halle:

Huid ind head, a6

Ann uul head, ...... S

Hand and umbilical coril 5

Both lu»id<^, , . 4

Fool »nd hand, 2

Two hands, unihilical cord, and fool ■

Face, hand, and cord. I

Kietz found in 7555 labors the foot and head presenting in 23.'
The cause of compound presentations is usually a lack of

Fig. 396, — Compound presentation : head and fool (author'

conformity in the presenting part with the pelvic inlet, as in mal-
position of the fetus, a head of abnormal size, a displaced uterus,
twins, hydramnios, contracted pelvis, and anomalous shape of
the uterus.

In the treatment of compound presentations before rupture of
the membranes an attempt should be made to overcome the
difficulty by postural treatment. The woman should be placed
on that side opposite the prol.ipsed extremity. After rupture of
the membranes an attempt should be made to dislodge the pro-
lapsed extremity and to restore it to its natural position. Version

"Diss. Inaug.,'' Berlin,

SlS THE PATHOLOGY OF LABOR.

may, however, be required if this attempt (ails, or even crani-
otomy if the child is dead. If the head and extremities present,

and if the former is engaged, it is usually best to apply forceps
and to disregard the prolapsed extremities. In the case of
nuchal position of the arm, an effort should be made to dislodge
the latter, but it may be necessary to fracture it before the
delivery of the child can be secured.

Multiple Births.— Iwin labors arc usually easy and uncom-
plicated (75 per cent.), but complications are more frequent
than in single labors. Malpresentations are common. The
following table from Spiegelberg. based on 1138 labors, gives
the combined presentations in the order of their frequency ;

Both hcods presenting, . .

Head and breecb

Both pelvic presenlations, .

. 3' 70 '

8,60 ■

. 6.iS •

f cei

ANOMALIES JN THE EORCES OF LABOR.

519

It may be noted that a transverse position is found in 10,67 per
cent, of cases. Mechanical difficulties in labor are frequent : the
uterine muscle is usually weakened by overstretching, and there
may be trouble in the third stage of labor in the delivery of the
placenta. Some form of operative interference is demanded in
about 25 per cent, of all cases.

Fig. 399- — I-ockiiig of hcBds in twin labor.

In the majority of cases (79 per cent.) the interval between
the delivery of twins is les.s than an hour. A longer delay
than this indicates the likelihood of some obstruction to the birth
of the second infant or a failure of expulsive forces.

Serious difficulty in twin labors may arise in one of three ways :
Both heads present at once, one a little in advance of the other,
the second impacted in the neck of the first (Fig. 398) ; the first

520

THE PATHOLOGY OF LABOR.

child descends by the breech, and the head of the second child is
caught by the chin of the first and pushed into the pelvis (Fig.
399) ; one child sits astride of the other, which is transverse. If
both children should be found attempting to engage by the head
in the superior strait at one time, one child should be retarded
while the other is artificially extracted. If this is impossible, the
first head should be extracted by forceps, the second be treated
in like manner, and then the trunks should be delivered one after
the other, Hmbryotomy is a last resort, but is scarcelj- e^cr
neccssarj'.

A coiling of the cords (Fig. 400) and their entanglement may
be a source of difficulty and delay in
unioval twins. It may be necessary
to cut one or both cords between
ligatures before the children can be
delivered.

In case one child presents by the
head and the other by the feet, bolh
may come down together, and the
two heads become locked in the pel-
vic entrance and canal. An effort
may be made to push back the child
presenting by the head. If this suc-
ceeds, the child presenting by the
breech should be extracted immedi-
ately, for it is in imminent danfjer
from asphyxia. It may be possible
with forceps to pull the child pre-
senting by the head past the body of
its fellow presenting by the breech.
Failing in these attempts, the child
Kig. 4'-o — KniinsUmeni of presenting by the breech will almost
™^ '" '""" '^^"»^'^'="- surely have died, and there will be no
pulsation in its cord. It should then
U.' dtv.ipit.itcd. n hereupon the infant presenting by the head can
be i-McicUxi wilh.nit difficulty by forceps.

In ,i:iv c.tst- oi" twin labor, as soon as the first child is bom.
JUS.', the ivrd. lib;uli.d with a double ligature, is cut, the attendant
*iv*ii;d !!«nKxlt.tti.lv in\estigate the position and presentation of
SV #t-o.»iKl child. A neglect of this rule leads very often to the
■«(ftijh.t:^vi of an unrtvoLinized shoulder presentation in the second
Shisv -t^'--- !ts coiisei.!UiTH death. If an abnonnality is discovered
^t. rt<- ■.wsf.ittation of thf -iecond child, it should at once be cor-
fpnA'. ^1■^'n. •ift'-'' waitinj: perhaps half an hour, the amniotic
^4i,~ sKNtlti N.' ruptured, and ergot may be administered in a full

I dose

F retain

A.V0.1UL/ES IN THE FORCES OF LABOR.

S3I

dose to secure a speedy delivery, or, if the stomach will not
retain it, tile hypodermatic syringe should be used, for, the birth-
canal having been dilated thoroughly, there is no obstacle to the
birth of the second infant in twin labors, and consequently no
objection to the employment of ergot, which not only hastens the
conclusion of labor, but promotes subsequent contraction of the
much-distended uterus, and so prevents postpartum hemorrhage.
As a further precaution against this accident which is always

Fig. 401

threatened in twin labors, the fundus should be compressed for
an hour or two after birth by the nurse.

There may be difficulty in the delivery of the placentae in twin
labors. Commonly the children are bom first and the placenta;
afterward. Their bulk may make expre.ssion difficult, and it is
often necessary to make some traction upon the cords — first upon
one and then upon the other — to determine which placenta will

522 THE PA THOL OG V OF LABOR.

come first and to assist in its expulsion. Occasionally one and
rarely both placentae may be expelled after the birth of the first
child. In a case of the writer's the placenta of the first child,
prolapsing in front of the second, necessitated a difficult forceps
operation for the extraction of the second. On account of the
frequent and extensive anastomoses between the vessels of the
placentae in unioval twins it is a necessary precaution to tie the
cord of the first child with a double ligature and to cut it between
the ligatures ; otherwise the second infant might bleed to death.

The prognosis of twin labors is always doubtful. There are
so many possible dangers {hx both mother and children that
multiple labors must be regarded as distinctly pathological.
Albuminuria in the mother is the rule in multiple pregnancies,
and eclampsia is ten times more frequent than in single births.^
There is a disposition to inertia uteri during and after birth from
distention of the cavity, and consequently a likelihood of post-
partum hemorrhage. Some operative interference or intra-
uterine manipulation is called for in about twenty-five per cent
of cases, and this, in addition to the frequency of kidney insuf-
ficiency, predisposes to sepsis. Finally, there maybe insuperable
obstruction in labor if locked twins are not managed properly,
and the woman may die of ruptured uterus or of exhaustion.
The maternal mortality in the Budapest Maternity was four
times as great as in the single births, and Klein wachter's statis-
tics give a mortality of thirteen per cent. For the children there
is greater danger than for the mother. Twin pregnancy is
almost always prematurely interrupted, and even if it is not the
children are, as a rule, under the normal size and weight. There
is always the possibility that the development of one child at
least will be seriously interfered with by the lack of room in the
uterine cavity. Hydramnios of one sac and oligohydramnios of
the other are not uncommon. In labor there are frequently
complications from malposition, operative interference, entangle-
ment of or pressure upon the cords, and more rarely the engage-
ment of both bodies at once in the pelvic canal. In Klein-
wachter's and Kezmarszky's statistics the fetal mortality was
nearly forty per cent. Of thirty-eight children in cases of locked
twins, only six survived, — a mortality of eighty-four per cent.

Cases are on record in which an extra-uterine fetus has
obstructed the delivery of the intra-uterine twin. It has been
necessary to make a vaginal incision through which the former
was extracted before the latter could be bom.

* *'he fetus during or before labor, followed by rigor

apsia, 69 were multiple pregnancies (Winckel).

ANOMALIES IN THE FORCES OF LABOR. 523

mortis, has proven a source of obstruction in labor by the rigidity
of the child and the consequent interference with the normal
mechanism of its delivery, especially of the shoulders and trunk. ^
Ankylosis of the large joints of the extremities may have the
same effect to a less degree.

Labor Complicated by Abnormalities in the Fetal Appendages. —

Membranes, — If the membranes are too thin, they may rupture

prematurely, and thus give rise to what is called a "dry labor,"
in which the birth-canal must be dilated by the hard, unyielding
presenting part instead of by that conservative hydrostatic dilator,
the bag of waters. Such labors are longer and more painful
than the average, and there is a greater likelihood in them
of lacerations in the cervix and a more frequent demand for an
artificial termination with forceps. If the membranes are too
thick, they rupture late, being preserved perhaps until the child's
head presents at the vulvar orifice, or even until the complete
escape of the head from the mother's body. In these cases the
head and face are covered by the membranes as though by a veil,
and care must be taken to free the mouth and nose quickly, that
respiration may be instituted without interference. The mem-
branes thus covering the head and face are spoken of as a " caul."
It is possible for the whole ovum to be extruded unbroken at
term. The writer has seen this occur as late as the seventh
month, and it is actually recorded at the full period of gestation.

Difficulties in labor may be encountered in consequence of an
abnormality in the quantity of liquor amnii. If there is too little,
the labor has the same clinical features as though there had been
a premature rupture of the membranes. If there is too much
liquor amnii, there may be inertia as the result of overstretching
of the uterine muscle-fibers.

Umbilical Cord, — If the umbilical cord is too short, it may
cause premature detachment of the placenta or may prevent the
advance of the child. The diagnosis of a short cord in labor is
always difficult. It may be suspected, however, if there is
exaggerated pain at the placental site, marked recession of the
head after each pain, and an obvious retardation of labor without
other ascertainable cause. Forceps should be applied in such a
case if the presentation is cephalic. If the cord is too long, it
may possibly prolapse should there be other conditions in the
labor favorable to such an accident ; or it may be coiled about
the child's neck, trunk, or extremities, and may consequently be
fatally compressed during labor (Fig. 402).

Obstruction of a mechanical character in labor on the part of

* Feis, "Uebcr intrauterine Leichenstarre," "Archiv fUr Gynakologie," Bd.
zlvi, H. 2.

LABOR COM PL ICA TED BY A CCI DENTS AND DISEASES. 525

before its expression is possible. Retention of the placenta may
be due to its great bulk, as in twin placentae, or to tumors
increasing its size. In such cases it may be necessary to extract
the placenta manually.

LABOR COMPUCATED BY ACCIDENTS AND DISEASES.

Hemorrhage. — One of the gravest and, unfortunately, one of
the commonest accidents during and directly after labor is hemor-
rhage. The causes of hemorrhage during the first and second
stages of labor are placenta praevia, premature separation of a
normally situated placenta, rupture of the uterus, lacerations
along the lower birth-canal, and rupture of a blood-vessel or of
a hematoma. The causes of hemorrhage during the third stage
of labor and directly afterward are relaxation of the uterus, lacera-
tions of the birth-canal, rupture of blood-vessels or of hema-
tomata.

Placenta Prsvia. — By placenta praevia is meant the attach-
ment of the placenta to the lower uterine segment. In some
varieties of the condition the placenta presents itself first to the
examining finger, and may even emerge before or in front of the
child ; hence the name.

History. — Early writers (Guillcmau and Mauriceau, 1609-
1668) recognized placenta praevia, but they explained it as an
accidental prolapse of the placenta. Portal (1685) described it
more correctly, though indistinctly. Schaller (1709) demon-
strated the condition in the dissection of a body. From Levret's
time placenta praevia was well understood. Rigby (1789) defines
it as the attachment of the placenta to that part of the womb
which always dilates as labor advances — a definition that is
strictly accurate to-day. It is to Rigby, too, that we owe the
term "unavoidable hemorrhage " to describe the hemorrhage of
placenta praevia, as opposed to the ** accidental hemorrhage *'
from premature detachment of a normally situated placenta.

Frequency, — Placenta praevia varies in the frequency of its
occurrence in different localities and at different times, as the
following table demonstrates :

Cases of
Number of Placenta
Rbportbr. Labors. PRi«viA. Proportion.

C. V. Braun 7,853 15 1-522

Hugcnberger , 8,036 42 X-X91

Ix>mcr 6,862 136 1-50

Winckcl (1873-78) 6,324 7 1-903

Winckcl (1879-87) 8,500 30 1-283

Mailer 876,432 8x3 X-1078

Lack i x,55o o 0-0

Schwarz 5*9.328 332 X-X564

Midwives* report in Saxony (1878) . . 1x9,553 7^ I-X532

LABOR COMPLICATED BY ACCIDENTS AND DISEASES. $27

Etiology, — A perfectly satisfactory explanation for the occur-
rence of placenta praevia has not yet been found. Clinical ob-
servation shows that any chronic inflammation or congestion of
the womb predisposes to it. Hence placenta prasvia is three to
six times more common in multiparae than in primiparas, and is
more often met with in the working classes. Uterine myomata
and carcinoma of the cervix, are predisposing causes, on account,
no doubt, of the endometritis that accompanies them. Ingelby
reports two cases of abnormally low situation of the tubal orifices,
in one of which placenta praevia occurred three times ; in the
other, ten. Multiple pregnancies, according to Winckel, furnish
four times as many cases of placenta praevia as do single preg-
nancies, and a woman beginning to bear children late in life is
liable to placenta praevia in subsequent pregnancies. Uterine
malformations are apparently a predisposing cause. A case is
reported by Schwarz of uterus bicomis in which placenta praevia
recurred three times.

Hofmeier and Kaltenbach^ furnish the best explanation for
the abnormal situation of the placenta. These observers have
demonstrated, by the examination of young ova, that the chorion
villi in the lower pole of the ovum may develop in an hyper-
trophied decidua reflexa, thus carrying the placenta down to and
across the internal os. At first an adhesion between the decidua
vera and the reflexa is prevented by catarrhal discharge, but as
the ovum develops the reflexa may adhere to the vera, thus
fixing the placenta in its abnormal situation, permitting its con-
tinued growth, and giving rise to an apparent hypertrophy of
the decidua serotina.

Varieties. — Four divisions are made of cases of placenta praevia
—central, partial, marginal, and lateral. In the first the center
of the placenta lies over the internal os ; in the second the
greater mass of the placenta lies upon one side of the lower
uterine segment, usually the left (56 : 37, Miiller), though the in-
ternal OS is completely covered by it ; in the third a margin of
the placenta projects over the internal os ; in the fourth the
placenta is situated upon one side of the lower uterine segment
and only the edge of it projects into the cervical canal, if it
does so at all, when the os is fully dilated. This classification is
justified upon clinical grounds. In central and partial placenta
praevia the hemorrhage begins early in pregnancy, is profuse and
frequently repeated, and in labor is more dangerous than is the
hemorrhage of the lateral variety. There is an added difficulty,
too, on account of the obstruction offered by the placenta,

1 «* Lehrbuch der GeburtshUlfe."

528 THE PATnOLOGY OF LABOR.

stretched across the internal os, to the spontaneous descent of the
child, or to the physician's efforts to reach and extract it. In
lateral placenta praevia hemorrhage usually does not occur till
labor is well advanced, and often does not appear at all. Lateral
and marginal placenta praevia are the commonest varieties. In
270 cases the placenta was marginal and lateral 217 times ; cen-
tral and partial 53 times (Winckei). Strictly speaking, central
placenta previa is very rare. There is almost invariably more
of the placenta on one side the internal os than on the other.

Fig. 404.— Varieties of

lacenla prscvia: in A there are se

en the aomai. lateral.

n B there are represented the iiri

cenU at the fundua, which is

rat^, and implanlaliuD over the i

lemal os : in C lalera

implantalion and that of a

cotyledon imiuedialely over the

litemalos: and in D

partial implanlatirjn (Dickies

on).

CliMual History. — A woman with placenta prajvia may begin
to bleed as early in pregnancy as the second month, but the first
hemorrhage usually occurs in the last trimester. There is a sudden
gush of blood, often without apparent cause and without pain.
The bleeding commonly recurs in increasing amounts and at de-
creasing intervals as pregnancy advances. In \ery rare cases
the blood leaks away continuously (stillicidium), though this is

LABOR COMPLICATED BY ACCIDENTS AND mSEASES. 529

more characteristic of the premature separation of a normally
situated placenta. The cause of the hemorrhage during preg-
nancy is the impact of the embryo and fetus upon the placenta.
the pressure of the ovum upon the lower uterine segment, and
the imperfect attachment of the placenta in certain areas to the
uterine wall. A prediction of the amount of bleeding in labor
can not always be made by the amount of blood lost or the fre-
quency of the hemorrhages in pregnancy. The first hemorrhage
may occur in labor, which may be ushered in by a tremendous
outpour of blood, even in lateral placenta pr^evia. Ordinarily,
however, the greater the bleeding during pregnancy, the more
likelihood is there of serious hemorrhage Jn labor. The bleed-
ing in labor is easily explained. The placenta is attached in that
portion of the uterine cavity which must be dilated to allow the
advance of tlie presenting part. The stretching of the uterine
walls expands the area of the placental site, and necessarily de-
taches the placenta, while the reversal of the ordinary mechanism
of placental detachment keeps the gaping mouths of the torn
uteroplacental vessels wide open, and allows the blood to pour
from them till the hemorrhage is checked by syncope, by throm-
bosis, by the pressure of the presenting part, or by a vaginal
tampon. The source of the bleeding in rare cases is a rupture
of the circular sinus of the placenta, a laceration of the fetal
vessels or of the cervix.

The bleeding is usually most profuse just as the uterine con-
traction passes oR! During the height of the pains it may cease
altogether, from the pressure of the presenting part or of the
intra-uterine contents upon the placental site.

As the placenta occupies a portion of the space in the lower
uterine segment and may prevent the descent of the presenting
part, abnormalities in the presentation and position of the fetus
are common. Transverse and oblique positions are ten times,
breech presentations four times, more frequent than in normal
labor.

In the first stage of labor, inertia uteri is common, partly be-
cause the cervix is not pressed upon and reflex irritation is absent,
partly on account of the loss of blood.

The OS is usually patulous, even before labor begins, and the
cervical canal is easily dilated. Occasionally, however (twelve
per cent.), the os is contracted and the cervix rigid.

The insertion of the cord is often marginal or velamentous,
and prolapse of the cord is common.

The placenta is often anomalous in shape, size, thickness, and
weight. There is frequently a placenta succcnturiata. As the
OS dilates the placenta may be torn and thus separated into two

5 30 THE PA THOLOG Y OF LABOR,

parts. An adherent placenta may be expected in more than a
third of the cases (Miiller, thirty -nine per cent).

After labor there is a tendency to inertia, and consequently
to postpartum hemorrhage, and there is an extraordinary liability
to septic infection.

Placenta praevia, as a complication in labor, would be much
more common than it is if it did not so often interrupt pregnancy.
The frequency of abortion and miscarriage is placed in different
statistics at forty to sixty per cent.

In quite a large proportion of cases placenta praevia would
be unrecognized in labor without a careful examination of the
membranes and placenta afterward. Even in the marginal
variety the presenting part, unobstructed, may descend quickly,
exerting such pressure upon the placental site that bleeding does
not occur.

Symptoms and Diagnosis. — Repeated hemorrhages during the
latter part of pregnancy make the diagnosis of placenta praevia
almost certain. On digital examination the cervix is found
enlarged in all directions ; the vaginal vault is soft and boggy ;
the presenting part can not be plainly felt ; pulsating vessels are
detected around the cervix ; the external os is dilated and the
cervical canal is patulous to the internal os, through which a
finger can easily be pushed. Under favorable conditions the
placenta may be felt through the abdominal walls, as was first
pointed out by Spencer. Finally the maternal face of the placenta
or its margin is felt over the internal os, the uneven surface of the
cotyledons and a gritty feel distinguishing it from a blood-clot,
the membranes, or the presenting part.

During the first stage of labor the causes of hemorrhage are
lacerations of the birth-canal, rupture of blood-vessels, and
placenta praevia. The hemorrhage of placenta praevia occurs
early, with unruptured membranes, with feeble pains or in their
absence altogether, and the symptoms of uterine rupture and of
lacerations along the lower birth-canal are absent. In the rare
event of a ruptured blood-vessel along the lower birth-canal, the
blood does not flow from the uterine cavity.

Treatment, — If a placenta praevia is detected during preg-
nancy, gestation should be terminated at the end of the seventh
month, or at any time thereafter that the diagnosis is estab-
' The hemorrhage before the thirty-second week is
"'angerous,^ though in one case I was obliged to
^ore the fifth month on account of a loss of
t incessant. After the seventh month the

liner's statistics there was not one before the seventh

LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 531

532

THE PATHOLOGY OF LABOR.

may bleed to death at any time before medical aid can
reach her. The induction of labor and its conduct should be as
follows : Send for an assistant to administer an anesthetic ;
place the woman in the lithotomy position, with her knees sup-
ported by nurses or attendants ; cleanse both hands and arms as
for a surgical operation ; wash out the vagina with tincture of
green soap and hot water by means of pledgets of cotton ; give
a vaginal douche of bichlorid of mercury i : 4000 ; dilate the
cervix by inserting first one finger, then a second, and next the

Ftg. 406. — Placenla prscvm; v^na lamponed wilh gauie (DickJnionl.

thumb of the right hand ; search on the woman's left side for the
edge of the placenta ; pass two fingers beyond it : perform bipolar
version, assisted by the left hand externally ; rupture the mem-
branes ; seize a foot and extract it until the knee appears at the
vulva; then withdraw the anesthetic. If the bleeding has been
alarming up to this time, it will cease as soon as the child's
breech is impacted in the pelvic canal. From time to time the
protruding leg may be gently pulled upon to hasten the dilata-
tion of the cervical canal, but plenty of time must be allowed for it ;

LABOR COMPLICATED BY ACCIDENTS AXD DISEASES. 533

otherwise the head is caught by the circular fibers of the
cervix and the child is asphyxiated by the pressure upon the
cord. At the expiration of an hour or more the child may
be safely extracted. If the operator finds a rigid cervix and
experiences great difficulty in its manual dilatation, he may
employ Barnes' bags ; but under anesthesia, and with a fair
amount of strength in one's fingers, hydrostatic dilatation
is scarcely ever required. If a physician discovers placenta
prEEvia for the first time in labor by a profuse outpour of blood
when the dilatation of the cervical canal begins, he should imme-
diately pack the vagina as full as it can possibly be packed. The
best material for this purpose is iodoform gauze if it is at hand,
but a clean towel torn into strips will answer. The tampon
serves the double purpose pf surely controlling the hemorrhage
and assisting the dilatation of the o.s. After a delay of an hour
or two to allow time for the os to dilate, the patient is anesthe-
tized and the operator proceeds as before described. If there is
great difficulty in finding the margin of the placenta and the
membranes beyond it, too much time should not be lost in the
search. The placenta should be perforated and the child's leg
pulled through the perforation. If the operator distrusts his
ability to perform the version as quickly as it should be done (for
the hemorrhage is likely to be furious during the attempt), he may
adopt a plan of treatment proposed by Wigand at the end of the
last century. This consists in tamponing the vagina firmly and
allowing the tampon to remain in place till the os is fully dilated.
If the labor lasts too long, the tampon must be removed, the
vagina douched, and a fresh tampon inserted. It is well to unite
with the tampon treatment the procedure recommended by
Barnes — separating the placenta by a sweep of the fingers around .
and beyond the internal os. This p!an \vas suggested by the
clinical observation that when the placenta separated and the
presenting part descended the hemorrhage ceased. The com-
bination of the Barnes and the Wigand treatment gives fairly
good results so far as the mother is concerned, though it
increases the risk of the sepsis. For the child it would seem to
be bad. but we have testimony from Wigand, Murphy, and
Winckel to the contrary. The fetal mortality is 48. 5 per cent.
(Winckel). In cases of marginal placenta pra;via in which
hemorrhage first occurs after the os is fairly well dilated, in
which the head presents and is easily accessible, the best treat-
ment is rupture of the membranes, application of forceps, and
traction upon the head till the bleeding ceases : whereupon the
instrument may be removed and the labor allowed to terminate
spontaneously.

534 "^ff^ PATHOLOGY OF LABOR.

It may finally be necessary to detach an adherent placenta, to
control a postpartum hemorrhage, and to treat the woman for
acute anemia.

Prognosis. — The study of the mortuary statistics of placenta
previa is not very profitable. It appears that the maternal death-
rate in general has been about forty per cent., including the deaths
from sepsis. But with the plan of treatment just described, car-
ried out by men who understand aseptic methods, the mortality
almost disappears. Thus, Lomer (16), Hofmeier (37), Behm(35),
and the writer (16) have had 104 cases, with i death (Hof-
meier's). For the children a mortality of fifty per cent, and over
may be expected. The outlook for the child is worse the more
nearly the placenta pn-evia is central.

Fig. 407,

bleeding (Dickinson).

Premature Detachment of a Normally Situated Placenta. — Tile

placenta may become detached during pregnancy or before the
third stage of labor, though it occupy a normal position near the
fundus uteri. The necessary consequence is hemorrhage, often
called "accidental," to distinguish it from the "unavoidable"
hemorrhage of placenta pr.-evia. If the lower margin of the pla-
centa is detached, the blood separates the membranes from the
uterine wall and escapes externally. The bleeding may. how-
ever, be entirirly Concealed (1) if the center of the placenta is
alone detached ; (2) if the upper margin is detached and the
'cumulates between the membranes and the uterine wall ;

LABOR COMPLICATED BY ACCIDEXTS AXD DISEASES. 535

(3) if the membranes arc ruptured far from the internal os and
the bl(X>d mingles with the hquor amnii ; (4) if the cervix is ob-
structed by a blood-clot, the membranes, or the presenting part
(Goodell). Concealed hemorrhage is, fortunately, ran;.

Camcs. — The cause of premature detachment of the placenta
may be obscure. The accident may occur during sleep and
xvithout ascertainable cause. The causes arc often, however,
those of abortion : nephritis, congestion of the pelvis, external
violence, physical effort, emotion. Prolongation of pregnancy,
with irregular uterine con-
tractions, was accountable
for one of my cases. Death
and disease of the fetus.
hydramnios, a short um-
bilical cord, and multiple
pregnancy may cause it. It
occurs more frequently in
multipara: and toward the
close of pregnancy.

Symptoms and Diagno-
sis. — Accidental hemor-
rhage, especially if con-
cealed, should be recog-
nized without delay. The
accident usually occurs be-
fore labor begins or in the
first stage. The uterine
contractions become weak
and finally cease, being re-
placed by persistent and
severe pain, usually at the
placental site. There is
shock, the signs of internal
hemorrhage become more
and more apparent, and the
uterus is distended by the
accumulation of blood within it. Feeble but persistent contrac-
tion of the upper part of the uterine muscle may be felt. If
there is a retroplacental effusion, a localized bulging at the
placental site maj- be made out by abdominal palpation.

The symptoms resemble somewhat those of rupture of the
uterus. In both there are hemorrhage, shock, and perhaps sud-
den excruciating pain. But in rupture of the uterus the accident
occurs late in labor, the membranes are broken, the presenting
part recedes, the uterus is well contracted, and perhaps its con-

'ig. 40S- — Freniaiure detachment n( the
L'U|)ying iu iiornial Eite. Fnuen
section 01 on nndeli»cred woman dead of
eclampsia. .\ blood-n
(after Winter).

>a under (he placcala

THE PATHOLOGY OF LABOR.

536

tents are evacuated into the peritoneal cavity; while in accidental
hemorrhage the detachment of the placenta occurs early in labor.
the membranes are not ruptured, the presenting part does not
recudc, and in concealed hemorrhage the uterus is distended by
the accumulated blood. In frank accidental hemorrhage the
diagnosis rests between detachment of a normally situated pla-
centa and placenta praivia. The presence or absence of the latter
is determined by a careful internal examination.

In excejitional cases a frank accidental hemorrhage appears
as early in preg;nancy as the
fourth month. Abortion usu-
ally follows, but I have seen
two cases in which the bleed-
ing continued uninterruptedly
for weeks, a large blood-clnt
formed between the site of
the placental separation and
the external os, and septic
symptoms supervened. In
spite of these unfavorable con-
ditions pregnancy continued,
and the fetus lived until I was
obliged to terminate gestation
on account of the anemia and
the symptoms of systemic in-
fection.

Prognosis. — The mortality
in accidental hemorrhage is
high. Goodell's statistics, the
best ever collected, give 54
maternal deaths out of 107
cases, and of the 108 children
(there being one case of twins)
only 7 were saved,
una vamien. Treatment. — The main ob-

ject of treatment is to evacuate
the womb as speedily as possible, so that the uterine muscle may
contract. At the same lime it mu.st be remembered that the
woman is in no condition to endure much additional shock. The
best procedure is to dilate the cervix with Hames' bags or
with the fingers, to perforate the membranes, and then to extract
the child by the quickest plan available. If the presenting part
is not engaged, the child should be rapidly extracted by the
leg. If the head is en;^agetl and a rapid forceps operation is
practicable, the instrument should be employed. If not, crani-

409 —Acci Menial heninnhage.
d colltfcird ticLwecn placealu and part
embrniie* and the uterine wall (Pinard

LABOR CO.MPLlCAThD BY ACCIDE.XTS A.\D DISEASES.

olotny should be performed. Ergot should be administered
hypodermatically, for postpartum hemorrhage is to be fuared.
A Porro- Cesarean section should be considered in the gravest
cases, in which a continuance of hemorrhage and the shock of
a forced delivery are more to be dreaded than abdominal section
and puerperal hysterectomy.

Postpartum Hemorrluge. — Hemorrhage may occur during the
third stage of labor, or in the first twenty-four hours of the puer-
perium, from rela.xation of the uterine muscle, from injuries along
the birth-canal, from ruptured vessels, tumors, malignant growths,
or ulceration in the parturient tract.

Postpartum Hemorrhaee from Relaxation of the Uterine Muscle.
— When the placenta is separated from the uterine wall and tiie
large maternal blood-vessels communicating with it are neces-
sarily torn across, every woman after labor would bleed to death
were it not for the following provisions on the part of nature to
prevent hemorrhage : Leukocytes begin to block the uterine
sinuses in the tatter weeks of pregnancy, and the excess of the
fibrin -making elements in tlic blood of pregnant women, together
with the sluggish blood-current in the sinuses, favor the forma-
tion of firm blood-clots in their orifices when they are torn ; the
uterine muscle contracts the moment the uterine cavity is emptied,
so that the blood-channels running through the uterine walls arc
ligated throughout their whole length by the contracting muscle-
fibers that encircle them ; the quality of retraction in the uterine
muscle maintains what is gained by contraction. It is to the last
two actions mainly that a woman owes her immunity from hemor-
rhage after labor.

The causes of postpartum hemorrhage are. therefore, those
which interfere with uterine contraction. They are ; Systemic
weakness from disease ; unfavorable hygienic surroundings or
anxiety ; weakness in the uterine muscle-fibers themselves, as
when they are undeveloped, fatigued, overstretched by hydram-
nios or twins, inactive by reason of surrounding inflammatory
products, exhausted by many previous labors, or too suddenly
called upon to contract by a rapid labor, especially if it is instru-
mental : anomalies in the innervation of the muscle-fibers ; a
mechanical obstacle to firm contraction, as a retained placenta or
clots within the womb, old adhesions upon its peritoneal surface.
or a tumor such as a uterine fibroma, an ovarian cyst, a dis-
tended bladder or rectum, that by its bulk keeps the womb
distended or displaces it. Some sudden effort may displace the
clots in the uterine sinuses and thus favor hemorrhage, as
coughing, sneezing, .sitting up in bed. or defecation. Heart and
lung disease or arterial tension from any cause may produce

538 THE PA THOLOG Y OF LABOR.

a congestion of the womb that predisposes to postpartum
hemorrhage.

Symptoms mid Diagnosis. — There is no difficulty in recogniz-
ing postpartum hemorrhage when the blood soaks through the
mattress and runs across the floor in a stream. The bleeding
should be detected early, however, that it may be arrested at
once. There is usually a sudden gush of blood, followed by
the expulsion every few seconds of several ounces of liquid
blood and clots. The uterus is relaxed and it is difficult to
outline it through the abdominal wall. There is an absence of
that firm, round, easily palpable tumor usually filling the hypo-
gastrium, characteristic of a firmly contracted womb. The con-
stitutional signs of hemorrhage become rapidly more and more
evident. The face is blanched, the pulse is quick and feeble,
vision fails, there is air-hunger, and the woman, to satisfy her in-
stinctive craving for more oxygen in the rapidly emptying blood-
vessels, makes a curious sound between that of a gape and a sigh.
Finally, there are restlessness, jactitation, convulsions, coma, and
death.

In exceptional cases one tremendous outpour of blood, last-
ing not more than five minutes, kills the patient. One can not
always judge the extent of the hemorrhage by the amount of
blood that escapes externally. The dilated womb may contain
enough within its cavity to cost the woman her life.

Very rarely, indeed, an uncontrollable postpartum hemorrhage
is seen from a firmly contracted and an uninjured uterus. It
occurred once from a ruptured aneurysmal vessel ; again in con-
nection with nephritis, presumably from atheromatous or diseased
vessels ; in one case from a ruptured hematoma of the cervix ;
in another from ulceration of the cervix that opened the uterine
artery ; in another from a ruptured varicose vein in the cervix.
Cases have been reported of paralysis of the placental site, with
firm contraction of the remainder of the womb. ^

In high altitudes postpartum hemorrhage is said to be much
more common than at lower levels, from the lessened atmos-
pheric pressure. I have been told, by physicians practising in
the high regions bordering upon the Rocky Mountains and in
South Africa, that they have this complication to contend with
very frequently.

Treatpnent. — Postpartum hemorrhage may occur after any
labor. Measures to prevent it consequently form part of the

'^ labor, as already described. If any
' of uterine relaxation exist during

Veit, vol. ii, pp. 121, 130.

LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 539

labor, additional precautions should be taken. As soon as the
presenting part emerges from the vulva a syringeful of the fluid
extract of ergot should be injected into the woman's thigh, the
placenta should be expressed without too much delay, and the
womb should be kneaded and compressed more vigorously and
for a longer time than usual, until it remains firmly contracted
and shows no disposition to relax. Then a large abdominal pad
should be laid above the umbilicus and a firm abdominal binder
should be adjusted. The nurse should receive instructions to
watch the patient's appearance closely, to count the pulse fre-
quently, and occasionally to turn down the bedclothes and
observe the quantity of the discharge.

Should hemorrhage occur in spite of these precautions, it
must be controlled with the least possible delay, for so much
blood is lost in a short time that the woman may die of acute
anemia, even though the bleeding be finally checked.

The beginner will do well to bear in mind the following plan
of action that he may put it into immediate effect, without de-
pending too much upon his presence of mind, readiness of re-
source, or self-command-^-qualities that perhaps are lacking
when he is first confronted with one of the most alarming acci-
dents of obstetric practice :

Seize the fundus uteri with one hand through the anterior
abdominal wall ; knead, compress, and rub it vigorously with
the fingers applied to the posterior uterine wall, the palm to the
fundus and the thumb in front, until the womb is felt firmly con-
tracting. If external irritation does not effect the desired result,
insert the free hand into the vagina, pass it into the uterine cavity,
feel for retained fragments of the placenta, blood-clots, or other
substances that might by their bulk prevent contraction, remove
them, and while doing so rotate the hand somewhat roughly, so
as to bring it in contact rather forcibly with the uterine wall ; at
the same time continue the kneading, rubbing, and compression
externally. If the combined irritation of the exterior and interior
of the womb fails to secure firm contraction, try next the irri-
tating effect of cold. Rub a piece of ice upon the hypo-
gastrium. If the effect of cold is not immediately satisfactory,
do not persist in its use, for the ultimate effect is relaxing
rather than stimulating. A ready and convenient method of
violently chilling the hypogastric region is to pour some ether
upon it The irritation of cold having proved ineffective, a
jMece of sterile gauze should be soaked in vinegar, carried to
the fundus of the uterine cavity, and squeezed out. Vinegar
is irritating and astringent ; it is clean and readily procurable
in every household. It has proven itself a valuable agent in

TBE FATBOLCGY Of LABOR.

tccarng die cootiaction of a rdaxed uterine muscle, and in
CK^ckisf pcecmtum bemorrhage. Should this meatu fail, the
moTDc <3«'it>' $bouM be packed n^ith iodoform gauze. In the
iatra-Kaiine tampon ve possess the surest and most reliable
lacxTii of coniroUing postpartum hemorrhage.' The technic
of riHffl^g the tampon is shown in figure 410. The end of
the iSiip should be inserted as ^ as the fundus b\- a Ion;;
p^acKital ibrvcps. and the Zi-hoie uterine ca\it}- firmly packed
mrh the s:;coessive lajms.

Other agents of \alue in
promoting uterine contraction
are hot water, electricitj-, and
st\-ptic or irritating drugs.
such as Monsel's solution,
iodin. and tuqjcntine. An
intra-uterine injection oi vcrj'
hot water ( 120° F. ) is effl-ct-
ive, but it is difHcult to regu-
late the temperature in private
practice without the assistance
of a trained nurse. A strong
_ faradic current is extremely

.'^^i^^'Ci jS^^^^^*^ eflficient, but a batter>- is
Qflk |T j^^^^l. - scarcely e\er at hand Hhi--n
T* I 4^ il f '* '^ needed,

J\ j fjl 1 \ Monsel's solution will stop

C- "y 1 u-SWn '^^ bleeding, but it leaves

' T.'oJ^r ^"'^*' fi"^' 3nd adherent clots

in the uterine cavity that sep-
ticemia will ver>- likely follow
from their decomposition, and
there is danger, besides, of an
extension of the thrombosis
to the uterine and pel\-ic ves-
seis. iodin and turpentine have done good service bj' their
initadnj: qualities, but there is danger of metritis from their
use. and they might leak into the abdominal cavitj- through
the tubes. Great virtue has been claimed for special modes
of compressing the uterus (Fig. 411) that are supposed to
close the mouths of the bleeding vessels. When these methods
art erfective it is by irritating the uterine muscle, rather than
by the pressure exerted upon the vessels of the placental

- P=hres*n, ■■ I'ehet die BehandloDg der Blutungcn pesi

F^ jio. — P»i-»ing Ihe puerperal

Volk-

ffTS AND DISEASES. 54 1

site. Compression of the abdominal aorta lias been proposed
as a means of checking postpartum hemorrhage by diminishing
the blood-supply to the womb. This plan, in my opinion, is
absurd. When it has apparently succeeded it was by the irrita-
tion of the womb, or of the sympathetic nerves supplying it, on
account of the deep abdominal pressure above the fundus.

Finally, the bleeding may cease spontaneously by thrombus
formation or by syncope, but these agencies are never to be
awaited in practice.

The physician's duty is not always done when he has checked
the bleeding. An acute anemia must be dealt with that, if dis-
regarded, will be as dangerous as a continuance of the hemor-
rhage. There Is a rapid, feeble pulse ; or, it may be, an entire
absence of radial pulsation. The body-surface, especially of the

Fig. 411. — Bimanual compression or thi

extremities, is cold, and there is a disposition to syncope on the
slightest effort There is loss of vision, and the acute anemia of
the brain may even lead to convulsions. With the dangers of
heart-failure and cerebral anemia in mind, the physician, while
engaged in stopping the bleeding, directs the nurse to raise the
foot of the bed on some books or bricks, and, if there is a
tendency to repeated syncope, to give a hypodermatic injection of
ether ; or. if it is at hand, of nitroglycerin (two drops of one per
cent, solution). As soon as the hemorrhage is checked, an
enema of a pint of hot water containing about forty grains of
common salt should be given. There is no better method of trans-
fusion than the recta! injection of a normal salt solution, and the
hot water raises, somewhat, the body-heat. The patient should,
in addition, be surrounded by hot bottles, should be well covered

542

THE PATHOLOGY OF LABOR,

with blankets, and should be kept at absolute rest, with the body
and head on a straight line and the foot of the bed well elevated
to keep as much blood as possible in the brain. Heart-stimu-
lants—digitalis, strychnin, nitroglycerin, and ether — should be
given hypodermatically if the heart-action fails to improve.
There is likely to be nausea and vomiting, but, as soon as the
stomach will retain what is put in it, the woman should receive
very small quantities of hot milk, hot concentrated coffee, hot
water and brandy, frequently repeated. When reaction is once
established, a hypodermatic of morphin hastens the patient's
recovery from the effects of the hemorrhage and prevents sec-
ondary shock by promoting physical quiet, calming nervous rest-
lessness, and producing some degree of cerebral congestion. In

desperate cases in which
the measures just de-
scribed are without satis-
factory result, a pint to
a quart of a sterile nor-
mal salt solution (0.6
per cent), at blood heat,
should be injected by
gravity into the loose
cellular tissue between
the shoulder-blades (hy-
podermoclysis ), under
the breasts, or directly
into an artery or a vein.
A convenient apparatus
for this purpose is shown
in figure 412, but it will
scarcely ever be at hand
when wanted, and, be-
sides, time is wasted
looking for and laying bare a blood-vessel. A good substitute
for the transfusion apparatus is a large aspirating needle and a
fountain syringe or funnel. With this appliance, with which
every obstetrician should be provided, fluid may be forced into
the cellular tissue or into a blood-vessel. The funnel and needle
should have a place in every well-supplied obstetric-instrument

emities should be bandaged toward the trunk (auto-

to force as much blood as possible to the heart,

•channels, and the brain. Compression of the

Ips to this end. Actual transfusion of blood

another, or from some animal, is no longer

Fig. 412. — Intravenous injection.

LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 543

advisable. It is rarely practicable, and the results are no better,
if as good, than are obtained by the injection of salt solution.

The physician should make it an invariable rule to stay with
his patient until her condition is entirely satisfactory. The anemia
persisting after the hemorrhage is checked and reaction is estab-
lished should be treated by a full liquid diet, animal broths, and
iron. The intense headaches of cerebral anemia that may per-
sist or recur for some time are best treated with opium.

Lacerations of the Walls of the Birth-canal. — Any portion of
the soft structures surrounding the birth-canal, from the fundus
uteri to the vulva, is liable to spontaneous rupture, or to trau-
matic perforation during labor.

Rupture of the Uterus. — The uterus may be ruptured by over-
distention of the lower uterine segment. It may burst open from
top to bottom in certain diseased conditions of its walls. It may
be j>erforated by the operator's hands or by instruments. Its wall
may be perforated by a localized necrosis and ulceration. If the
rupture involves all the coats and opens a way into the peritoneal
cavity, it is called complete. If it spares the peritoneal covering
of the uterus, it is called incomplete.

Frequency, — The statistics of the frequency of ruptured uterus
vary greatly.

Randl found . . .
Jolly found , . .
Lusk found . . .
Collins found . .
McClintock found
Ramsbothan found
Garrigues found .
Winckel found . .
Harris found . .
Koblanck found .

I in

1200 labors

3403 •*

6000 •«

482 "

737 "

4429 ••

I "3

-5000 •*

666 "

4cxx> **

462 «•

Rupture of the uterus is much more common in the poorer
than in the richer classes, chiefly because the former have less
skilful medical attendants. Multiparae are more liable to the
accident than primiparae (88 per cent. : 12 per cent, Bandl). Dis-
ease of the uterine wall, as fatty degeneration, a myoma, a pre-
vious injury to or operation upon the uterus, as a former rupture
or Cesarean section, are predisposing causes.

Causes. — The most frequent cause of ruptured uterus in labor
is overdistention of the lower uterine segment, due to some ob-
struction which prevents the descent of the child through the
pelvic canal. ^ Bandl first pointed out this fact.^

^ A contracted pelvis is the most common cause of uterine rupture, and a justo-
minor pelvis is the kind of contracted pelvis most often accountable for it. In 1218
ruptures a coDtracted pelvis was the cause in 570 (Koblanck, " Uterusruptur, " Stutt-
gart, 1895). » " Uebcr Ruptur der Gebarmutter, " Wien, 1875.

544 THE PA THOL OG Y OF LABOR,

In a normal labor the lower pole of the uterine ovoid is gradu-
ally dilated until the fetal body passes through it into the vagrina.
If there is an insuperable obstacle to the descent of the child, as
a contracted pelvis, rigid soft parts, a tumor in the pelvis, over-
growth or enlargement of the child, hydrocephalus, an impossible
presentation or position, the contraction of the upper uterine seg-
ment continues until the child's body is driven in great part out
of it, but, descent of the child being prevented, it is crowded into
the enormously distended lower uterine segment and cervical
canal, while the firmly contracting upper uterine segment is
drawn up under the ribs until it sits upon the child's body like a
cap. There is a sharply defined line between the firmly con-
tracted thick wall of the upper uterine segment and the very thin
wall of the distended lower uterine segment, a line visible and
palpable running across the abdomen between the symphysis
and the umbilicus, approaching nearer the latter the greater the
distention of the lower uterine segment, the upper boundary of
which is normally about the level of the pelvic brim. This line
is called the *' contraction-ring " or the ** ring of Bandl." It
ordinarily coincides with the coronary vein of the uterine wall
and with the firm attachment of the peritoneum to the uterus.
It is not, as it was once supposed to be, the margin of the inter-
nal OS or the upper limit of the cervical canal ; it is the boundary-
line between that portion of the uterine muscle which contracts
firmly in labor, diminishing the area of intra-uterine space and
driving; the child out of the uterine cavity, and that portion of the
uterine muscle which must be distended in labor to allow the
passage of the child through the pointed end of the uterine ovoid.
If there is a greater bulk of the fetal body in one side of the lower
uterine segment, tlie contraction -ring is higher upon that side
and thus runs an oblique course across the abdomen. There is
a limit, of course, to the capacity of the lower uterine segment
and to the stretching and tenuity of its walls. That limit being
reached, the overstretched wall tears and the fetus may pass from
the uterine into the abdominal cavity. In rare cases the uterine
wall is weakened by a previous rupture, by a blow or fall during
pregnancy, by the scar of a Cesarean section, or by the removal
of a portion of tlic uterine wall in the excision of a myoma ; the
wall may be weakened by fatty degeneration, associated, perhaps,
with excessive general obesity '} prolonged pressure upon a small
area may destroy its vitality and lessen its resistance. In such

* In a case of uterine rupture seen with Dr. U. G. Hell, of Philadelphia, the
woman had become suddenly and enormously obese before her last pregnancy. She
luid experienced no special difficulty in the births of her other children, but in the last
^ilms ruptured after a few hours of moderate labor-pains.

LABOR COMPLICATED BY ACCIDENTS A\'D DISEASES. 545

cases rupture of the uterus may occur early in labor, or even
in pregnancy, without distention of the Iowlt uterine segment
tinaliy, external violence has ruptured or perforated the womb,
instruments inserted in the vagina have pierced its walls, and
the operator's hand inserted in the uterine cavity to perform
version has often been the immediate cause of rupture. ^

Morbid Anatomy. — Tiie tear in the uterine wall almost always
begins in the lower uterine segment, and usually runs trans-
versely. It may be upon the anterior, lateral, or posterior sur-
face. The edges of the tear are usually ragged, swollen, and
infiltrated with blood. The peritoneal covering of the uterus is
often stripped off for a considerable distance beyond the tear, and

in the sac thus formed between the peritoneum and the body of
the uterus the placenta may lie concealed, or even the fetus may
be contained. There may be an enormous subperitoneal hema-
toma or profuse intra]}eritoneal hemorrhage. The tear may run
upward toward the fundus, or may extend so far transversely as
almost to sever the upper and lower uterine segments. The rent
may extend through the mucous and muscular coats without in-
volving the peritoneum. The latter, in rare cases, may alone be

1 Koblanck (lo^. n't.) pves the following causes in 80 cues: Contracted pclrii,
8 ; Irsnsrerse position of (etus. 7 1 olber abnomiBl positions, 4 ; bydrocepIiHlus. 4 ;
overgrowth of child. 1 ; misfil of presenting |iart in pelvis, administnuion of ergot,
I: violence, 5: v«nion, 39; Hofmeier's grip. I; forceps, II; decapilalion, i;
myoma, i.
J5

^ 546 THE PATIJOLOGY OF LABOR. ^^^^^H

■ #5n\5

■ m :U

^H^ •vf "

s.^sf^s^''.-

^^^3

W Fig, 414— Transverse

or semicircular tear of the Io«

.,„.._.-l

P. I^\fe. 1

^^^^k j^^^^Bk ' ^^^K^K^f ^1

L ^P J

^^^B ,.: i™=r ^H

LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 547

split, and it is recorded in one case that the peritoneal and mus-
cular coats were torn while the mucosa remained intact.^ If the
tear is extensive and complete, the fetal body will probably pass
into the abdominal cavity, and intestines may prolapse into the
uterus and into the vagina. In one remarkable case^ there was a
tear of the lower uterine segment and of the right lateral fornix
of the vagina, through which the fetus entered the vagina, passing
to one side of the undilated cervix. Fetal death is usually syn-
chronous with the rupture of the womb, and if the child's body
passes into the peritoneal cavity it rapidly putrefies, generating

Fig 417 — Perforating 1

;ervix i rerfinl on * penloneu

I. muscle ; •!, poElenoc lip of ihe c
r, vaginal laceralioQ (Winckel),

gases of decomposition so quickly that its bulk is enough in-
creased thereby to enhance considerably the difficulties of its ex-
traction. From the decomposition of the fetal body, or perhaps
from the entrance of atmospheric air, there may be emphysema
of the pelvic connective tissue and even of that of the tJiighs,

' J, M. Witbrow (■■ Lancet-Clinic,'" December. iSgi) reports a case of ruptured
alerus. iho rem beginning in front, midway between the inaeition of the lubes, en-
lending up over the fundus and down along the posterior wall to l>ouglas' pouch,
involving the peritoneal coit and the muscular tissue, but not (he mucous niem)inLae.
The uterus, filled with water after removal fiom the body, did not leak. A larje
diHC of ergot bad been given during labor,

» Slajmer, '■ Ceiilralblatl f. Gyn ,"' No. 18, 1S95.

548 THE PATHOLOCV OF LABOR.

buttocks, mons Veneris, and abdomen. Sqitic peritonitis of a v
lent kind usually develops with great rapidity. In a minority of
cases the site of the rupture is walled off by a rapid outpour of
lymphandby agglutination of coils of intestines, leaving a compar-
atively small cavity to be drained through the tear. This cavity
may secrete ascitic fluid in large quantities for a time, and during
the woman's convalescence there may be a profuse watery dis-
charge from the womb. I have seen two such cases. Occasionally
a large area of intraperitoneal space is drained through the tear.
Even the fetal body may be encapsulated, and a llthopcdion

Fig. 4t8. — Uterus perlbiated hy the pressure of (be promontory : a. Perforal!^^^

j. lacetnlion of cervix; c,c,c. vsginal tears;
of cerrix (Winckel).

may be formed. In the uterine ruptures or perforations due
to pressure necroses the opening Is round in sliape, regular in
outline, and small in extent. The opening is almost always on
the posterior wall over the promontory of the sacrum. In the
rare cases of cxo.stoses of the pelvis the bony outgrowth may
pinch a hole in the uterine wall. In these cases the opening *
corresponds with the site of the exostosis.

Clinical History, Symptoms, and Diagnosis. — Rupture of the
uterus usually occurs after labor has lasted a long time, after
e of the membranes, and with a well-dilated os. There is

LABOR COMPLICA TED BY ACCIDENTS AND DISEASES. 549

usually an obstruction in the labor that should have been recog-
nized, the lower uterine segment is enormously distended, and the
contraction-ring is palpable and visible near the umbilicus ; the
pains have been vigorous and frequent, the woman's suffering has
been extreme, and the abdominal muscles have been employed,
perhaps, with each contraction, though the presenting part does
not descend the birth-canal. Suddenly there is a sharp, excruci-
ating, lancinating pain ; the woman may cry out that something
has happened to her ; the uterine contractions cease, blood flows
from the vagina, perhaps in alarming quantities, and the patient
presents every evidence of shock. On making a vaginal ex-
amination the physician finds that the presenting part has re-
ceded ; hitherto easily reached, perhaps at the very outlet of the
pelvis, it may be altogether inaccessible, and on passing the
hand into the uterine cavity the rent may be felt, or intestines
may be found within the uterus and protruding from the os. On
abdominal palpation the upper uterine segment may be felt firmly
contracted to the size of the uterus after labor, and the child's body
may be easily detected in the abdominal cavity alongside of it.

If the rupture of the womb is not complete, or is not large, it
may not be discovered until the child is born, and may never be
suspected at all unless the woman develops septic peritonitis
after labor or discharges ascitic fluid from the uterus. There
may be no pain at the time of rupture, no hemorrhage, no abnor-
mality of uterine contractions. Even with a complete tear of
large dimensions and escape of the child into the peritoneal
cavity there is occasionally an astonishing absence of symptoms.
I have seen a case in which the child passed into the abdominal
cavity twenty-four hours before I was summoned, and yet there
was no alarming symptom of any kind until suddenly, at the end
of twenty-four hours, the signs of virulent septic peritonitis
appeared. The accident of labor most commonly mistaken for
ruptured uterus is premature detachment of a normally situated
placenta. The distinction between the two should be made
easily by attention to the following differences in symptoms :

Rupture of the Uterus.
Occurs late in labor.

Membranes ruptured. Uterus diminished
in size by evacuation of some or all
of its contents into the abdominal
cavity.

Recession of presenting part.

Discharge of blood from vagina.

Exploration of the interior of the womb
easy, and rent accessible to touch.

Accidental Hemorrhage.

Occurs l)efore labor or early in the first
stage.

Membranes unruptured. Uterus dis-
tended, perhaps irregularly in retro-
placental effusions.

Position of presenting part unchanged.
No external bleeding in the concealed

variety.
Exploration of the interior of the womb

impossible.

5 50 THE PA THOL OG Y OF LABOR.

As the placenta is often detached when the uterus ruptures,
and as it may prolapse in front of the child, a ruptured uterus
may be mistaken for placenta praevia.

If the physician should have reason to suspect that the uterus
is ruptured during labor, he should extract the child without
delay and should then explore the uterine cavit>% preferably under
anesthesia, from top to bottom. By unvarying adherence to
this rule he will not be guilty of the serious fault of overlooking
a ruptured womb with few symptoms until septic peritonitis
occurs and all treatment is unavailing, or until the bleeding,
internal or external, is so profuse that the patient can not be
revived.

The symptoms during the puerperium indicative of a ruptured
womb in labor are : septic peritonitis, profuse uterine hydrorrhea,
secondary hemorrhage (as late possibly as the twelfth day —
Winckel), and the prolapse of the intestines. The last is the
only positive sign, unless, on the occurrence of the others, a
digital or instrumental examination of the uterine cavity reveals
the rent.

Prognosis, — The prognosis of ruptured uterus depends upon
the site, extent, and degree of the tear, and upon its treatment.
In ten cases of rupture of the anterior wall in the Berlin Mater-
nity every one ended fatally, and in three ruptures at the fundus
the result was the same.^ Incomplete ruptures are not so fatal
as those in which the peritoneum is also involved, and the result
depends somewhat upon the escape of meconium, liquor amnii,
blood, placenta, and fetus into the peritoneal cavity. Before the
advent of asepsis and the improvement in the technic of abdom-
inal surgery the mortality of ruptured uterus averaged about 90
per cent. Of late years the mortality has been much reduced. In
60 cases of complete rupture without active treatment the mortality
was 78.8 per cent., in 70 cases treated by irrigation and drainage
the mortality was 64 per cent., and in 193 cases treated by ab-
dominal section the mortality was only 55.3 per cent* In about
one-half the fatal cases death occurs within the first twenty -four
hours. The great majority of the remainder die within three days.
In some fatal cases, however, death occurs as late as the tenth or
fourteenth day. The causes of death, in the order of their fre-
quency, are sepsis, hemorrhage, and shock. The mortality of
the infants is usually over 90 per cent. In the 80 cases from the
Berlin Maternity 10 children were saved, but this is an unusually
large proportion. If the woman recovers from the rupture, she
runs a great risk of a repeated rupture in a subsequent pregnancy

* I have perfonned hysterectomy for a complete rupture of the uterus across the
^ndas, with success, in one case.

tUs, ••Intemat. med. Rundsch.," Jan. 10, 1892.

LABOR CO MP Lie A TED BY A CCIDENTS AND DISEASES. 5 5 I

and labor. There are cases on record, however, of women safely
delivered in a subsequent labor.

Treatment, — The preventive treatment of uterine rupture con-
sists in obviating, in time, the obstructions in labor that predis-
pose to the accident.

The treatment of the rupture itself differs as the rent is com-
plete or incomplete, as its situation admits of good drainage or
otherwise, and it depends greatly upon the escape of foreign
matter into the peritoneal cavity. The first care of the physician
must be to extract the child and to control the hemorrhage. If
the child has escaped into the abdominal cavity, no effort should
be made to extract it by the natural passages, but it should be
removed through an abdominal incision. If the rent is small,
and the child has only in part passed from the uterine cavity, it
should be delivered rapidly by version, the application of forceps,
or by craniotomy. The last is to be preferred. The placenta
may be removed by the vagina, even though it has passed into
the abdominal cavity ; but if difficulty is experienced in finding it,
\{ the cord should break off by the efforts to pull the placenta
through the rent, or if the placenta lies hidden under the perito-
neum stripped off the womb, its extraction should be postponed
until the abdomen is opened. In an incomplete tear it is sufficient
to pack the rent with iodoform gauze, in order to control hemor-
rhage and to secure good drainage. This may be preceded by
irrigation, which may be repeated with advantage when it becomes
necessary to renew the gauze packing. If the rent is complete,
but small, and situated low down upon the posterior wall ; if there
has been little, if any, foreign matter injected into the peritoneal
cavity, the same treatment will suffice ; but if the tear is exten-
sive, if considerable blood has passed into the peritoneal cavity,
and, all the more, if the peritoneum has become contaminated by
the entrance of liquor amnii, of the placenta, or of the child itself,
an abdominal section will be necessary. With the abdomen open
a decision must be made between several plans of procedure.
Usually, it is best to amputate the womb, if possible, below the
site of the tear. Occasionally, if the wound is not too ragged
and can be thoroughly approximated, it will be sufficient to unite
it with deep and superficial sutures, care being taken to cover
over the line of rupture with inverted peritoneum. In case the
peritoneum is stripped off the womb for a considerable distance,
and it is impossible to secure a good stump, a flap of peritoneum
may be dissected off the uninjured side of the womb and used to
cover over the upper portion of the stump and its denuded sur-
face ; or it may be preferable to do a panhysterectomy, sewing
up the opening left in the vagina in such a manner as to cover

552 THE PA THOL OG Y OF LABOR,

any denuded surfaces. If the tear is on the anterior wall, or at
the fundus, an abdominal section is necessary. On opening the
abdomen one of the procedures detailed above may be adopted,
or it may be possible, as it was in one of Leopold's cases, to splint
the womb by gauze packing in the pelvis and abdomen, so as to
bring the torn surfaces firmly together.

In an abdominal section for ruptured uterus the toilet of the
peritoneal cavity must be made, of course, with the greatest care.
It is better, if possible, to cleanse the abdominal cavity with pads
of gauze, rather than to flush it with water ; but the latter plan
is sometimes necessary to remove small clots of blood scattered
throughout coils of intestines or hidden in the depths of the
pelvis.

Injuries to the Cervix. — The cervix is injured to some extent
in every labor, but serious tears, that cause at the time profuse
hemorrhage and give rise to symptoms subsequently, are com-
paratively rare. The causes of serious injuries to the cervix are :
precipitate delivery, premature rupture of the membranes, forcible
extraction of the child by the forceps or after version before the
OS is thoroughly dilated, incarceration of the anterior lip of the
cervix between the child's head and the pelvis, and abnormal
rigidity of the cervix. The tear is usually bilateral, occasionally
unilateral, in rare cases multiple, and in one instance under the
writer's observation directly in the anterior median line. In rare
instances the tear, instead of being longitudinal, may be circular,
and in consequence the vaginal portion of the cervix may be
completely torn off from the womb.

The cervical tear manifests itself immediately after delivery of
the child, usually by some hemorrhage, occasionally by profuse
and dangerous bleeding. A digital examination of the vagina
directly after the extraction or expression of the placenta always
informs the careful physician of the condition of the cervix, and,
if the good rule is followed to inspect the cervix through a
speculum before ceasing to attend an obstetric case, a torn cervix
that needs attention should never be overlooked.

The hemorrhage from a torn cervix directly after labor may
be controlled in two ways. First, by ligatures, which are per-
fectly certain to eflcct the desired result, but which are not always
easy to insert, and which increase the danger of septic infection,
unless the attendant possesses gynecological skill and has the
necessary equipment for operating in a perfectly aseptic manner.
The easiest, and on the whole safest, plan for checking the hem-
orrhage from a torn cervix in general practice is to insert a
tampon in the form of a half ring in the lateral vault of the
vagina. The best tampon material is iodoform or sterile gauze.

LABOR CO MP Lie A TED B Y ACCIDENTS AND DISEASES, 553

I have never known this device to fail in checking hemorrhage
from a torn cervix.

It is a moot question whether a torn cervix should always
be immediately repaired. My conviction is that, in general
practice, the attempt had better not be made, for the follow-
ing reasons : Stitches placed in a relaxed cervix directly after
labor will probably not be tight enough at the end of twenty-
four hours to close the wound. To place them properly re-
quires considerable skill, and necessitates dragging the cervix
into view by bullet forceps. The necessary instruments are
rarely to be found in the general practitioner's armamentarium,
and, the most cogent reason of all, the majority of lacerated
cervices heal spontaneously, if the woman is kept quiet on her
back in bed for a sufficient length of time, without vaginal
douching or other interference that could disturb the approxi-
mation of the edges of the tear. If it appears better in an in-
dividual case to repair immediately a torn cervix, the operation
should be done as follows :

The woman should be placed in the dorsal posture on a table,
her buttocks projecting well beyond its edge, the tjiighs flexed
on the abdomen, the legs upon the thighs.

An anesthetic is not absolutely necessary. The anterior and
the posterior lip of the cervix should each be caught by a bullet
forceps. The cervix is pulled into sight, and by separating the
bullet forceps the tears are made to gape. Sutures (silkworm
gut) are then inserted in exactly the same manner as for the
secondary operation by Emmet's straight cervix-needles. Three
sutures on a side are usually sufficient. They are knotted or
shotted as the operator prefers, and the ends are left at least an
inch long to facilitate their removal. The sutures may be re-
moved in two weeks.

Circular Detachment of the Vaginal Portion of the Cervix During
Labor. — In very rare cases the whole vaginal portion of the cervix
is torn off from the womb and emerges from the vulva in front
of the child's head. This accident may be the result of extreme
rigidity of the cervix, or of the cervix being caught between
the walls of the pelvis and the child's head, if the former is
contracted or the latter is very large. I have seen two examples
of this accident, both due to extreme rigidity of the cervix
(Figs. 419 and 420). In each case the woman was an elderly
primipara, and was quite obese. One of them was delivered a year
later under my charge without difficulty. In one case (Fig. 419)
there was a narrow tab of cervical tissue left in the median line
f>osteriorly. Although the injury at first sight appears serious.

SS4

THE PATHOLOGY OF LABOK.

there is no hemorrhage in consequence of it, nor is the puerperal
convalescence disturbed. This accident could almost always be
averted by multiple incisions in the cervix.

Lacerations of the Vagina. — The vagina may be torn by the
insertion of the hand, by the rapid extraction of the child, by

Figs. 419 BiUd 420. — Autboi

the extension of tears irom the cervix, by the propulsion of the

child's body against the posterior wall without sufficient deflec-
tion forward to facilitate its escape from the vulvar orifice, and.
most frequently of all, by the blade of a forceps which docs not
fit the child's head properly, or which is not used with sufficient

LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 555

care as to the direction of the force that is applied in the extrac-
tion of the head.

The tears of the vagina accompanying a lacerated perineum
or injured pelvic floor are described under the latter heading.

Tears of the vagina extending from the cervix involve
usually the lateral vaginal vaults, occasionally opening deep
rents into the base of the broad ligaments, and involving possibly
the uterine arteries or even the ureters. The hemorrhage from
these tears is best controlled by ligating the bleeding vessels if
they can be found, or by firmly tamponing the rent if it is impos-
sible to locate the bleeding points. Drainage must be secured
by gauze packing, and, when the wound begins to granulate,
daily washing with sterile water should be employed. The tears
of the posterior vaginal wall sometimes result in perforations of
the rectum, and in consequence a portion of the child, as an
extremity, may emerge from the anus.^ These perforations
should be repaired immediately after labor by buried sutures of
catgut and interrupted stitches of silver wire or silkworm gut.

The tears of the anterior vaginal wall made by a forceps-
blade are almost always clean-cut, and are apt to bleed pro-
fusely. They should be closed by a running catgut suture.
In one case under my care the hemorrhage was so profuse that
it was impossible to see the wound at all, and there was danger
of the woman bleeding to death while I attempted to sew it up.
After several abortive attempts the wound was successfully
repaired without further bleeding by pushing a tampon into the
vagina and following the tampon as it was pushed up along the
course of the wound with a needle and thread, until the upper
end of the tear was reached.

Lacerations of the anterior and posterior vaginal vaults pen-
etrating to the peritoneal cavity are usually associated with rup-
ture of the uterus. They are to be treated by gauze packing and
drainage.

Lacerations and Abrasions of the Vulva, of the Vestibule, and of
the Vaginal Entrance. — The most frequent site for injuries in this
region is the upper portion of the vestibule and the tissues on one
side of the clitoris or of the urethra. Tears in this situation bleed
profusely, and they are so common that it is a valuable rule of
practice always to look in this region for injury when there is
a hemorrhage from the vagina after labor with a well -contracted
womb. The bleeding points are in plain sight, and the hemor-
rhage is easily controlled by a stitch or two, deep enough to
undersew the whole depth of the tear. A catheter should be

» Piering, ** Ccntralblatt f. Gyn.," No. 48, 1891.

556

THE rAlJWLOGV OF LABOR.

558

THE PATHOLOGY OF LABOR.

placed in the urethra to guard against occluding it. In abrasions
of the labia and of the vestibule care must be taken that the raw
surfaces shall not unite causing atresia of the vagina. This can
easilvbe pre\ented by laying oiled lint over the raw surfaces, and
by the use of douches

Figs. 427 and 4zS. — Fcrfonuions and laceradoos of the nymphs (Bar).

Lacerations of the Perineum. — The causes and preventive treat-
ment of lacerations of the perineum are considered elsewhere.
The repair of the injury is dealt with in this section. The com-
monest form of torn perineum is shown in figures 430 and 43 1.
It may be seen that the tear rarely involves the perineum alone,
but usually extends up the posterior wall of the vagina, on one
or both sides of the posterior column. Experience teaches, more-
over, that lacerations of the perineum alone, when they do occur,
have very little effect upon the patient's after -condition, even
though they reach to the anus and sever the transverse perineal
muscle (see Figs. 434, 435). The greatest care should be ex-
ercised, therefore, to ascertain the extent of the injury to the
vagina which may be associated with the tear of the perineum.
This is best done by placing the woman in the dorsal position
across the bed, with her thighs well flexed upon the abdomen
and widely separated, and with the buttocks projecting beyond
the edge of the bed. A nurse or other assistant, whose hands
are protected by clean towels, holds the labia apart, and the
physician cleanses the torn surface of the posterior wall of the
vagina with pledgets of cotton soaked in bichlorid of mercury
solution. In this way the exact nature and the extent of the

LABOR COMPLICA TED BY ACCIDENTS AND DISEASES.

559

injury may be seen. The laceration should usually be immedi-
ately repaired ; the woman is very likely still stupid from the
effects of the anestiietic tiiat has been administered in the second
stage of labor, and the parts are benumbed by the pressure to

Fig. 430,— Deep laccralion of Ihe
perineum and of one suk-us; spliU in
t1)e vaginal mucous membrane (Bar).

Fig. 432..— Laceralion of the peri-
n and of (he sulci ; abnuioni of

™lva(!!ar).

which they have been subjected, so that the pain of the small
operation is slight. But if the physician is tired out by long
attendance upon a case, if the light is poor, if sufficient help is

560 THE PA THOLOG V OF LABOR.

not at hand, or if he does not possess all that lie needs in the
way of implements, he had much better postjione the repair of a
lacerated perineum until a more convenient time, within twentj'-

Figs. 434 nnd 435-— '-sc

eralioni of Che peiini:ii

m without in

voWemFnt

or the

Ivic floor. Such lea... ^-Qy!

1.1 noi affect llie worn

ari'f health i

ir comfuH

tnl»c-

™tly (Bar).

four hours of its occurrence. The simplest way to sew up a
lacerated perineum that does not involve the sphincter ani is
shown in figure 436. All that is needed for the operation is a
curved needle set upon a handle and a few strands of silk-

worm gut. The suture material and the needle should be im-
mersed in boiling water for five to ten minutes before they are
used. The woman is kept in the dorsal position across the bed ;
the thighs are well flexed and widely separated, the feet resting
upon chairs. The operator inserts the forefinger of his left hand
in the rectum and measures the depth and extent of the tear
with his thumb in the vagina. The needle is then plunged
deeply into the pelvic muscles, so that it encircles the wound
I throughout its whole depth and emerges on the opposite side

I near the upper margin of the tear. The eye is threaded by an

I assistant, and the needle is then withdrawn. This suture is re-

peated from three to six times, according to the extent of the
tear. If care is taken to insert the needle deeply enough, and
to put the first stitch near the upper margin of the tear through-
out its whole depth, a thoroughly satisfactory and strong union
of the parts can be secured by an operation of the simplest pos-
sible nature, easy for the veriest tyro in surgery to peribrm, and
lasting not more than five minutes. Another plan to be recom-
mended in the hands of experts accu.stomed to gynecological
surgery is to sew up the lacerated perineum and torn vagina in
the same manner that one inserts stitches for the secondary
operation upon the perineum, after the plan of Emmet. If the
perineum is torn through the sphincter into tlie rectum, the best
36

THE PATHOLOGY OF LABOR.

LABOR COMPLICATED BY ACCIDENTS A^'D DISEASES. 563

mode of suture is shown in figure 437. Silkworm-gut sutures
are inserted first in the rectum and knotted there, with the ends
left long enough to hang an inch or more outside the anus. Two
stitches should be inserted from the rectal side, through the ends
of the torn sphincter muscle : and directly above the sphincter a
stitch should be placed triangularly in the torn perineum, skirt-
ing the whole extent of the rectal tear, entering and emerging
upon the skin of the perineum just above the anus. This resem-
bles somewhat the stitch recommended by Emmet for a torn
sphincter and rectum, but of itself it is not to be depended upon.

Rg. 439. — Viginoperineal laccr- Fig. 440. — Complcle laceration of the

uion involring both laleial sulci. perineum : perineorrhaphy. Emmet's roeih-

Threc internal, or vaginal, and two od ; lightening the posterior suture, which

external, or perineal, sutures in place includes the sphincter,
ready to be titid.

As a reinforcement of the sphincter and rectal stitches, however,
it does good service.' The torn perineum is then repaired in the
manner already described, either by long, deep stitches passed
with a curved needle, as in the first operation described, or by
stitches inserted as in the Emmet or Hegar secondary operation.

In the rare cases of central tears of the perineum, an attempt
should be made to repair the injury by vaginal and perineal
sutures, but a secondary operation for a perineovaginal fistula
may be necessary.

Inversion of the Uterus. — This is the rarest of all the acci-
dents to a parturient woman. In tlie Vienna Maternity, from

had a single failun

ccondary o]

564 THE PATHOLOGY OF LABOR.

1849 to iS^S, in more than 250,000 labors, there was not a c
In the Rotunda Hospital, in Dublin, there were ioo,000 labon
with only one inversion of the womb. Winckel has not seen ^
case in 30,000 labors. My own experience amounts to thn
cases — two complete and ont: partial. In general practice, csp<
ciaily among the poorer classes, inversion of the womb 1;

Figs. 441, 44J, 443,

{■'Prtcisd' Obslelriquc"!.

rare. The accident happens with equal frequency before and after
the delivery of the placenta. The inversion may be 1
complete, the former when the fundus simply protrudes ii
uterine cavity, tiie latter when the womb is turned compic
inside out. In a complete inversion the fundus is just within tl

LABOR CO MP Lie A TED BY A CC IDE NTS A.\D DISEASES. 565

vulva ; the cavity of the womb is formed by the peritoneal sur-
face, the orifice looking upward into the peritoneal cavity. From
this cavity the tubes and the ovarian and round ligaments run
upward ; the ovaries are usually above and to cither side of the
orifice. In the rarest instances inversion of the womb may be
associated with inversion of the vagina. In such a case the in-
verted womb is also prolapsed.

Causes. — Inversion of the uterus may occur spontaneously.
In the so-called paralysis of the placental site. — a condition in
which this portion of the uterine wall becomes so relaxed and
flabby that it sags down into the uterine cavity, — the projecting
portion of the wall, it is said, is seized upon by the remainder of
the uterine muscle as a foreign
body, and depressed further and
further toward the cervical canal,
as a polypoid tumor might be
expelled. The explanation, how-
ever, is strained. A contraction
of the uterine muscle under these
circumstances would reinvert the
womb. A much more plausible
explanation for spontaneous in-
version is found in an adherent
placenta and entire relaxation of
the uterine walls. In this condi-
tion of aflairs the mere weight of
the placenta is enough to drag
the fundus down into the uterine
cavity. A most favorable predis-
posing cause is furnished by a
complete inertia uteri at the close
of the second stage of labor. The
expressive force of the abdominal
muscles not only expels the child's
body, but drives down the uterus after it. Inversion of the
uterus may be most frequently explained by traction on the cord
in the third stage of labor, when the placenta is adherent. It
may occur in consequence of a short cord pulling upon the pla-
centa during labor. In a case under my observation the cord
was wound three times around the child's neck. It is sometimes
due to too vigorous compression of the fundus in eflbrts to ex-
press the placenta, and I have seen it occur on one occasion in
an effort to extract an adherent placenta, in which the hand and
the placenta grasped within it acted like the piston of a syringe
and drew the fundus down into the uterine cavity. A necessary

Fig. 445. — Paitial

566 THE PATHOLOGY OF LABOR.

predisposition to inversion of the womb is relaxation of its walls.
If the uterus is firmly contracted, the accident can not occur.

Symptoms. — Inversion occurs suddenly, and is usually asso-
ciated with profound shock, and often with some hemorrhage.
The patient at once passes into a most alarming condition, that I
can scarcely fail to attract any one's attention. The only causes i
for her condition would be hemorrhage, rupture of the Uterus,

fig 44ft _( mplete nitrsi
majora L Inbin minorn D clito:
der of (he vagina , G exietnal border of the tw uteri ; //, the internal suKace of 1I
uterus now eHernil (Buivin and Diigis),

syncope, or inversion. An immediate vaginal e.vamination should
always be made, whereupon the nature of the trouble should mani-
fest itself at once. The inverted uterus is found filling up the
vagina, and almost projecting from the vulva. By abdominal
palpation one notes the absence of uterine tumor in the hypo-
gastrium, and can detect, moreover, a groove or slit running
s of the cervix. If necessary, a rectal exam-

LABOR COMPLICA TED BY ACCIDENTS AND DISEASES. 567

ination would reveal the absence of the womb and the depression
in the cervix where it is inverted even more plainly than these
signs could be detected by abdominal palpation ; but a rectal ex-
amination should scarcely ever be necessary. The cervix itself
remains uninverted as a collar about the lower uterine segment.
Between the cervix and the uterine wall a sound or the finger
may be inserted a little way, but it is impossible to find a uterine
cavity. This fact should always make the distinction between an
inverted womb and a fibroid polypus or other tumor projecting
from the uterine cavity. Mistakes, however, of the most serious
character have been made in this connection. In one case the
inverted womb was torn away in the belief that it was a fibroid
tumor, and in another the wire of an ecraseur was adjusted about
an inverted womb, and was about to be screwed tight, when the
true character of the mass in the vagina was detected.

Treatment. — Occasionally, a spontaneous reduction of the
inversion occurs, especially when inversion is partial. This
occurred in one of the three cases under my observation. If
the inversion is complete, spontaneous reduction can not be ex-
pected. If the placenta is still attached to the uterus, it should
be first removed, and then pressure exerted with the fingers upon
the lower uterine segment in a direction forward and slightly
upward. To do this, the hand must be inserted well into the
vagina and back toward the sacrum, and the fingers must then
be directed well forward toward the anterior abdominal wall, in
the direction of the axis of the superior strait. The mistake is
almost always made of pressing upward against the sacrum, so
that the efforts to reduce the womb may fail altogether, and a
chronic or permanent inversion may be left for the gynecologist
to deal with after the puerperium is completed. With the proper
direction of force in one's effort to reduce an inverted uterus,
failure ought to be almost unknown, if the reposition of the
womb is undertaken at once, as it always should be.

Strange as it may seem, the inversion has been overlooked
for some days or altogether in quite a large proportion of the
cases. If the cervix is allowed to contract firmly, as it will in
a few hours, the reposition of the womb becomes extremely
difficult. In one of my cases, seen in consultation, five days
had elapsed since the woman's delivery. She had suffered great
pain, had considerable fever, with a foul discharge, and had
a very rapid pulse, yet no vaginal examination had been made,
although the patient was in charge of a professed expert in
gynecology ! I found the womb completely inverted. Repo-
sition was accomplished, after most fatiguing exertion, by the fol-
lowing plan : One hand, made into a cone shape, was inserted in

568

THE PATHOLOGY OF LABOR,

the vagina and the finger-tips were pressed steadily against one
side of the lower uterine segment, forcing it into the cervical
ring. After steady pressure for almost an hour, the cervix yielded
considerably. Then an assistant helped in the dilatation of
the cervical ring, in the manner shown in figure 447, and at the
same time made counterpressure downward upon the cervix.
The womb was returned to its natural position shortly after
this manceuver was tried. The woman recovered.

Fig. 447. — I, Complete inversion of the uterus; 2, first manoeuver to reinvert
the lower uterine segment ; 3, second manceuver to widen cervical ring and afford
counterpressure by an assistant.

Prognosis. — The mortality of inversion of the womb has
been extremely high. In one series of 109 cases there were
80 deaths, and 72 of these • within a few hours after labor. In
another scries of 54 cases there were i 2 deaths (Winckel). The
three cases under mv care recovered. The causes of death are :
shock, hemorrhage, sepsis, peritonitis, and exhaustion from long-
continued loss of blood.

LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 569

Rupture of the symphysis occurs not infrequently,^ usually
in consequence of some disease within the joint itself, occasionally
as the result of great force in the extraction of the head with for-
ceps or after version. The accident may be recognized at the
time of its occurrence by feeling the bones give way, or by actu-
ally hearing them snap. But it may not be detected until the
woman complains of great pain in the symphysis, and of inability
to sit up or walk when she rises from bed. Not infrequently rup-
ture of the symphysis is followed by suppuration of the joint.
The accident must be treated by a firm binder around the hips,
such as is used after a symphysiotomy, and by keeping the patient
in bed four or five weeks. If the joint suppurates, it should be
opened as early as possible and should be well drained. The
prognosis of the injury is not serious. Recovery may be expected
as the rule, without impairment of locomotion or other disagree-
able consequences, if the cjmiphysis alone is injured.

Rupture of the sacro-iliac joints has the same causes as
rupture of the symphysis, and is often associated with it. Inflam-
mation and suppuration in these joints often follow their injury.
The symptoms in the puerpcrium are, great pain over the joints
on attempting to walk, a feeling of insecurity in the pelvic bones,
a wabbling gait, and loss of power in one or both lower limbs, with
fever if the joints are inflamed or suppurate. The only treatment
available is firm support of the pelvis by a pelvic binder, sand-bags
alongside the pelvis, and extension to the lower limbs, or, best of
all, the orthopedic surgeon's wire cuirass to immobilize the whole
body. Prolonged rest in bed — six to twelve weeks — is necessary.
In the case of suppuration of the joints, an incision into them from
behind to evacuate the pus and to allow of drainage is indicated.

The mortality of injury to the sacro-iliac joints in labor has
been thirty per cent.

Fracture of the Pelvic Bones. — This very rare accident in
labor has been the result of the unskilful use of forceps. It is
serious but not necessarily fatal. In a case reported by Studley,^
of a fracture of the horizontal and of the descending rami of the
pubis, the woman recovered.

Fracture of the sacrococcygeal joint, or of the coccyx,
occurs very rarely in elderly primiparse, in whom not only the
sacrococcygeal joint, but the joints of the coccyx as well, are
ankylosed. The fracture may be caused spontaneously by the
expulsive efforts of the mother driving the presenting part down
upon the pelvic floor ; but it is more commonly the result of the

* Ahlfeld collected 100 cases, to which number Schauta added 14 (Miillei's
"Handbuch").

' " American Journal of Obstetrics," April, 1879.

570 THE PATHOLOGY OF LABOR.

application of forceps and tilt forcible extraction of the head
through the pelvic outlet. There are. in my experience, four
tj-pes of cases in which the coccyx is injured in labor. In one
there is an oblique fracture of a coccygeal vertebra involving a
joint and resulting in painful mobility of the bone. In the second
there is ankylosis of the two fragments with the lower one drawn
in at a right angle, where it is out of the way and causes no
inconvenience or discomfort except in
a subsequent labor. In the third the
lower fragment is ankylosed in a per-
pendicular position, causing great
pain when tJie patient attempts to siL
In the fourth there is a strain, sprain,
or an actual rupture of a coccygeal
joint, with abnormal mobility and
chronic inflammation. The injury
often results in the condition known
as coccygodynia after the completion
of the puerperium.

Diastasis of tlie Abdominal
Muscles. — Reference has been made
to the escape of the uterus from the
abdominal cavity between the recti
muscles in labor. After delivery
tliese muscles stand widely apart and
threaten the woman with abdominal
hernia when she rises from bed. Even
without the escape of the uterus be-
tween the muscles and the probable
rupture of some of the aponeurotic
fibers of the median line, the recti
muscles may be separated so widely
during pregnancy and labor, and may
lie so far apart after delivery, as to
cause some anxiety that abdominal
hernia will result when tlie wonian
gets up. The condition can usually
be corrected by a firm abdominal binder during convalescence.
Rupture of Some Part of the Respiratory Tract, and Sub-
cutaneous Emphysema. — During the straining of the second
stage of labor, the laryn.\ or trachea may be ruptured. This
accident is followed by emphysema of the neck and face. The
accident, if confined to the trachea or larynx, and resulting only
in emphysema of the neck and face, is not dangerous. If the
emphysema is more extensive, however, or if there is a rupture
if the pulmonary vesicles, with emphysema of subpleural and

Fig. 44S.— Median seMion
of cnccyx imbedded in parafGii,
shoning an oblique fnclure run-
ning Ihrough the second vertG-
bra. Tbe vacanl space between
Ibe lower end of the anterior
fragmenl and tbe mnin body of
ihe bone *ns filled with an ex-
uberant mass of spongy Uaie-
Iksue that dropped oif when (he
bone waa Inken out (author's

LABOR COMPLICA TED BY ACCIDENTS AND DISEASES, 57 1

interlobar connective tissue, with embarrassment of heart and
lungs, the prognosis is not so good. As soon as the nature of
the injury is recognized the patient must be forbidden to strain, and
should be delivered as quickly as possible by forceps or version.

Sudden Death During or Directly After LaiM>r. — The causes
of this accident to the parturient woman are set down, as far as
possible, in the order of their frequency.

Shock. — A few sudden deaths during and after labor may be
explained by surgical shock, which is more likely to follow a
serious accident, such as ruptured uterus in labor, but may result
from the strain and suffering of parturition in weak, hyperesthetic
individuals, without any serious complication.

Heart-failure. — Heart-failure may be due to advanced kidney
disease, to fatty degeneration of the heart itself, to a fibroid patch
in its walls, to rupture of an aneurysm, to myocarditis, and to a
number of other conditions that might interfere with normal
heart-action. In women with diseased and weak hearts so small
a matter as an intra-uterine injection has caused heart-failure.

Accidents of L^bor. — Any of the serious accidents of labor
may produce death by shock or by hemorrhage, as accidental,
unavoidable, or postpartum hemorrhage ; rupture or inversion of
the womb.

Rupture of Hematomata. — A rupture of a hematoma, exter-
nal or internal, may kill a patient by shock or by hemorrhage.
In a case under my care a hematoma in the outermost part of
the left broad ligament, rupturing eighteen hours Sfter delivery,
caused death in a very short time by internal bleeding.

Syncope. — There is a disposition in most women after labor to
faint, but even complete syncope at this time is rarely fatal. If
it depends, however, upon hemorrhage, thromboses may form in
the heart, or those in the uterine sinus may be prolonged, and
embolism may result. Prolonged syncope, associated with air-
hunger and other symptoms of profuse internal hemorrhage, is
almost always fatal.

Embolism and Thrombosis of the Pulmonary Artery. — This
may be the result of syncope, or may be caused by the detach-
ment of an embolus from the pelvic blood-vessels. The
embolus, it is claimed, may be a globule of air,^ or may be fat
from the pelvic connective tissue. The symptoms of the acci-
dent are : sudden shock, a rapid-running pulse, heart-failure,
rapid respiration, air-hunger, followed usually in a few moments
by death ; but the accident is not invariably fatal. I have seen
one well-marked case recover. The only treatment possible is

' Since I saw my friend. Professor H. A. Hare, inject whole S3rringefuls of air
into the jugular vein of a dog without detriment to the animal, I confess to a skepti-
cism in regard to air-embolism as a cause of death in the child-bearing woman.

572 THE PA THOL OG Y OF LABOR,

Stimulation, slight elevation of the body, and lowering of the
head, with absolute quiet.

Profound Mental Impressions. — Profound emotion may cause
a woman's death during or directly after labor. The following
case was described to me by a friend who witnessed it. A
widow, in good position, applied for treatniient for abdominal
tumor. She was told that she was pregnant, but she vehemently
denied the possibility of her condition. A little later her phy-
sician was summoned to attend her in what he found to be labor.
He told her again of her condition, but she again denied it, and
throughout the whole of her labor she vehemently protested that
it could not be so. Finally, when the child was delivered, it was
held up before her as a proof that her physician was correct.
She passed at once into a maniacal condition, crying out that the
child was a tumor, that she had not been pregnant at all, and
after a few minutes she died. A careful postmortem examination
revealed no physical cause for her death.

Other causes of sudden death during and after labor that have
been reported are : rupture of a gastric ulcer, acute purpura
haemorrhagica, rupture of peritoneal adhesions, rupture of the
aorta, rupture of a cyst in the auricular septum of the heart, and
angina pectoris.

Effect of Maternal Death upon the Fetus. — ^The fetus rarely
survives its mother's death more than a few minutes, and usually
the death of mother and child is synchronous. An interesting
case was reported to me by a surgeon on an Antierican vessel in
the harbor of Rio Janeiro during the revolution in Brazil. A preg-
nant woman, near term, was struck by a fragment of an exploding
shell. She was killed immediately. She had scarcely fallen to
the ground when a surgeon, who was standing near her, cut open
her abdomen and uterus with a penknife, but the child was ex-
tracted dead. Tarnier reports an extraordinary case in which it
appeared that the child lived for two hours after its mother's
death. During the Commune in Paris the rioters fired upon the
Maternity Hospital. A pregnant woman, sitting upon her bed in
a ward, was shot through the head and instantly killed. After
a while she was discovered dead, and Tarnier was summoned to
do postmortem Cesarean section, as fetal heart-sounds were still
heard. Beginning the operation with his assistant, the rioters fired
upon the operators, and it was necessary to remove the woman to
the cellar before the attempt could b^ renewed. After an inter\'al
of an hour and three-quarters, or more, the operation was at length
performed, and a living child extracted from the mother's womb.

In case of death in a pregnant woman near term, the fetal
heart-sounds should be listened for carefully, and, if they are

LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 573

heard, an immediate attempt should be made to extract the child.
Tliis can be done by postmortem Cesarean section, or, better, 1
think, by forced dilatation of the cervix, version, and rapid ex-
traction. I have had one experience in such a case, in which
the dilatation of the cervix and the extraction of the child pre-
sented no difficulties at all, and were completed in a very few
moments. If the patient is seen in articuh mortis, it is unques-
tionably better to deliver her by forcible dilatation of the cervix
and version rather than to await lier death and then to perform
a postmortem Cesarean section.

Postmortem Delivery. — There is reported from time to time
the birth of a child in its mother's coffin, giving rise to the horri-
ble suspicion that the pregnant woman had been buried alive.
and had fallen into labor when she awoke from her trance and
realized her dreadful position. These cases, however, may be
explained by the accumulation of gas within the abdominal cavity
due to decomposition, which so increases the intra-abdominal
pressure as to drive the fetus out of the woman's body. Such
cases are more common in hot climates, where decomposition
progresses rapidly.

Accidents to the Fetus. — Prolapse of the Cord. — The cord is
said to be prolapsed when it presents with or slips beyond
the presenting part.

Frequency. — According to Winckel, the frequency of prolapse
of the funis varies in different clinics from i : 65 to 1 ; 500.
Churchill found it once in 245 labors ; Christisen, once in 65 ;
Meachcm, once in 93 ; Bland, once in 1897 labors.

Catisis. — ^Thc causes of prolapse of the cord are, in the first
place, a lack of conformity of the presenting part with the shape
and size of the pelvic inlet, as in a flat pelvis or a compound pre-
sentation, and with this condition an exaggerated length of the
cord, placenta previa, marginal insertion, hydramnios, sudden
rupture of the membranes and violent expulsion of the liquor
amnii ; delivery in the semirccumbent, sitting, or erect posture,
and violent jolts or jars such as a parturient patient would ex-
perience during transportation to a hospital in an ambulance.

The diagnosis '^ovAA present no difficulty. There is nothing
else in the cervical canal or vagina, during labor, which feels like
the cord or should be mistaken for it. It is sometimes actually
visible at the vulvar orifice, and may, in case of doubt, be pulled
out and inspected. If the child is alive, the pulsating vessels in
the cord may be felt. I was once called in consultation, how-
ever, by a young physician who believed that a coil of intestine
had prolapsed in the vagina.

The prognosis for the child is grave. The mortality in gen-

5?4 "/-^ PATHQLOG Y OF LABOR. T

eral is more than fifty per cent. The child obviously dies of
asphyxia from pressure upon the cord ; hence the danger i
wice as great in head presentations (sixty-four per cent) as ir
jreech presentations (thirty-two per cent.). The danger to the
mother lies in the operative procedures which are often require*
or the reposition of the cord, such as version and rapid extrac
tion.

Treatment. — The cord should be replaced by manipulation
with the woman in a knee-chest posture, or, better, the Trendelen
)urg posture — over the back of a chair. It is advisable to hook
A loop of the cord over an extremity or the chin to prevent it.

\g. 44') — 1 niuU t< 111 111 l; |'ii-(uri- uvtr a chair lo guard a prolapsed cord friiiii pies
-Lii.iii;.|l..f.n:i1iUleil5rcposilion ( Dkkinjoti)-

jrolapsing again, which is extremely likely. The whole ham
must be inserted in the vagina, and perhaps within the lowe
uterine segment ; so that anesthesia is usually required. While
the anesthetic is administered, and while the physician makes his
^reparations for the reposition, the patient should be kept in the
Trendelenburg posture, so as to guard the cord from fatal pres
sure. If the cord is satisfactorily replaced so thai it will no
come down again, forceps should be applied to the head to fix i
firmly over the pelvic inlet. !f manipulation fails to replace the
cord, podalic version should be performed without waste of time
The breech being firmly impacted in the pelvis, the case is man
aged as one of breech presentation — by delay until the os is wcl

LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 575

dilated and the cervix paralyzed, and then by rapid extraction,
ir the head is presenting and is engaged so that version is out
of the question, the cord should be so disposed as to be least
pressed upon (for example, opposite the left sacro-iliac junction
in a left occipito -anterior position of a vertex presentation) and
the head rapidly extracted with forceps. In
prolapse of the cord with a breech presentation,
the cord should be replaced by manipulation
in the Trendelenburg posture ; a foot should
be seized and brought down until the breech is
firmly impacted in the pelvis.

The instrumental reposition of the cord is
usually unsatisfactory and unnecessary. Man-
ipulation accomplishes more than can be done
by a repositor. Occasionally, however, it might
be convenient to remember the device illustrated
in figure 450. A loop of string or tape is tied
double around the end of a stiff" catheter or
bougie. The free loop is caught over the cord
and the end of the instrument which is carried
high up into the uterine cavity. Should it be
desirable to withdraw the instrument, it can be
done without pulling the cord out with it.

Rupture of the Cord. — It has been shown by experiments that
the healthy umbilical cord can stand a strain of 8j^ pounds
on the average, the weakest 5 % pounds, and the strongest
IS pounds. It is obvious, therefore, that the weight of an
ordinary fetus may be enough to rupture the cord, and it is
almost certain to do so if the weight is increased by a drop or
violent expulsion, and if the placenta remains attached. Hence,
precipitate delivery in the erect posture is often accompanied by
rupture of the cord usually at the umbilicus, although in one of
my cases it tore off at the placental insertion. Spaeth and
Budin have each reported a case of rupture of the cord while
the woman was recumbent, and the latter has also reported a
case in which the weight of the placenta, suddenly expelled and
dropping the full length of the cord, snapped the latter in two.
A ruptured cord usually docs not bleed. If it is torn off at the
umbilicus and the vessels bleed, they should be pulled out by a
tenaculum and ligated, or, if this is impracticable, hare-lip pins
should be inserted underthe umbilicus and a figure-of-eight liga-
ture applied.

The treatment of rupture of the umbilical cord is pre-
ventive. Labor in the erect posture should, of course, never
be allowed, and a precipitate labor must be retarded ; violent

576 THE PATHOLOGY OF LABOR.

traction upon a coiled cord has ruptured it It is better, in such
cases, to cut the cord between ligatures and to extract the child
quickly.

DYSTOCIA DUE TO DISEASE.

Convulsions. — Convulsions in the child-bearing woman may
be defined as muscular spasms, with or without unconsciousness,
occurring during pregnancy, parturition, or the puerperium.

Catiscs. — The convulsions may be due to eclampsia, hysteria,
epilepsy, tumors of the brain, meningitis ; to the profound an-
emia following postpartum and other hemorrhages, and to
apoplexy ; or there may be an exaggeration of the nervous irri-
tability characteristic of the child-bearing period, in consequence
of which convulsions may arise from some trifling irritation, as
that of an overdistended bladder, overloaded bowels, the intro-
duction of the hand in performing version, the pressure of the
head upon the perineum, and excessive after-pains. Puerperal
convulsions, therefore, are a symptom indicative of a variety of
pathological conditions.

Eclampsia. — This name is given to the most frequent variety
of convulsions in the child-bearing woman, the result of kidney
insufficiency. The name is derived from a Greek word signify-
ing to shine or flash out, and was conferred upon the condition
on account of its sudden onset.

Causes. — The etiology of eclampsia is still obscure. It has
been attributed to the accumulation of urea in the blood, or to the
formation of carbonate of ammonia in the system. It has been
ascribed to sudden anemia of the brain, and, by some French
observers, to microbic infection. All that can be said at present
is that eclampsia is the result of the retention in the body of
substances that should have been disposed of by the excretory
organs, mainly the kidneys, but which, owing to the insufficiency
of these organs, remain stored up in the body. The probable
result of these poisonous substances in the blood is the irritation
of the arterioles, causing sudden and extreme contraction of
their walls, producing in this manner an acute anemia of the
brain, which is in all likelihood the immediate cause of the con-
vulsions.

There must be taken into account also, however, the extreme
irritability of the child-bearing period, predisposing to convulsive
outbreaks, as it is not yet demonstrated that the substances in
the blood (whatever tlicy are) do not act directly upon the mus-
cular centers in the brain and spinal cord.

The kidneys in pregnancy may become insufficient for the
work of disposing of cxcrementitious matters from both maternal

DYSTOCIA DUE TO DISEASE. 577

and fetal bodies, by reason of the kidney of pregnancy, of ne-
phritis, of increased intra-abdominal pressure, or of direct pres-
sure upon the ureters. It is important in practice to appreciate
that the kidneys may be diseased and yet functionally sufficient,
or that they may be healthy anatomically, but functionally insuf-
ficient for their double work.

Frequency. — Eclampsia occurs about once in 300 cases of
pregnancy. It is most frequently seen in primiparae, and more
frequently in women illegitimately pregnant. It most often
occurs during labor, is next in frequency during pregnancy, and
occurs least frequently during the puerperium. It is ten times as
frequent in multiple pregnancies as in single pregnancies, and
occurs with greater frequency in climatic conditions which inter-
fere with the free activity of the skin and throw extra work upon
the kidneys.

Symptoffts. — Eclampsia should always be feared if. there are
signs of kidney disease or disturbance dunng pregnancy, for
diseased kidneys are more likely to be insufficient than healthy
kidneys. The prodromal symptoms of the attack itself are : Sharp
pains in the head, epigastrium, or under the clavicle ; muscae voli-
tantes, with failure of vision, great restlessness, or stupor. A few
moments after the appearance of the prodromal symptoms the
attack comes on with a stare ; the pupils are at first contracted ;
the eyelids twitch, the eyeballs roll, the mouth is pulled to one
side, the neck is then affected, and the head is pulled first toward
one shoulder and then toward the other. The spasm finally
spreads to the trunk and upper extremities ; the arms are strongly
flexed, the fingers are bent over the thumb, and the upper ex-
tremities work spasmodically to and from the median line in front
of the chest. The lower extremities are rarely affected, although
the thighs may be flexed tonically upon the abdomen. Con-
sciousness is lost during the convulsive attack and for some time
afterward ; with each recurring fit the stupor deepens, until at
length there is unbroken coma. The temperature usually rises
higher with each convulsion.

Differential Diagnosis. — The convulsions of eclampsia must
be distinguished from those of epilepsy, hysteria brain disease,
hemorrhage, or of some source of irritation within the body, as
mentioned above. The distinction should be made without diffi-
culty by an examination of the urine. If the patient is catheter-
ized, and the urine is heated in a spoon over a gas-lamp flame,
it will turn almost solid by the coagulation of albumin in it.
About sixteen per cent, of the cases of true eclampsia show no
albuminuria before the convulsions appear, but in every case,
after the second convulsion at least, the urine becomes strongly
37

578 THE PATHOLOGY OF LABOR.

albuminous. The other conditions causing convulsions in the
child-bearing woman have their distinctive signs (which it is not
necessary to recapitulate here) that serve to make the diagnosis
easy.

Prognosis. — In general practice it may be stated that the mor-
tality of eclampsia is thirty per cent., but in different localities,
and at different times, the mortality varies widely. For example,
the mortality in nine lying-in hospitals in this country during a
period of five years was 38.4 per cent, in 78 cases. The mor-
tality of the Royal Maternity in Edinburgh has been 66.6 per
cent That of Guy's Charity, in London, averages 25 per cent.
In 209 cases in the Maternite, in Paris, from 1850 to 1856, the
mortality was 33 per cent. Winckel reports 92 cases, with 7
deaths — ^a mortality of 7.6 per cent. Veit reports more than 60
cases, with 2 deaths — a mortality of 3.3 per cent. In 46 cases in
the Charite, in Berlin, there were 6 deaths, 2 of these being due
to complications, so that the mortality of the eclamptic cases w^as
8. 5 per cent. It is claimed that in Germany in general the mor-
tality in the last ten years has been reduced to b^ween 7 and 10
per cent, but during this period, in 80 cases in the University
Maternity of Berlin, the death-rate was 21.25 per cent.

The causes of death may be edema of the brain, of the lungs,
or of the larynx ; apoplexy, asphyxia, exhaustion, heart-failure ;
thrombosis and embolism in important vessels, especially the pul-
monary arteries, or an overwhelming accumulation of the poison
of eclampsia in the system. The mortality is greatest during
pregnancy and least in the puerperium.

The mortality of the child, if eclampsia occurs during preg-
nancy or labor, is about 50 per cent.

Treatment. — The preventive treatment of eclampsia has been
referred to in the section upon the Management of Pregnancy,
and under the head of Kidney Diseases during Pregnancy. The
treatment of the eclamptic convulsions themselves is best dealt
with by considering, first, the different plans of treatment
separately, with their results, so that their relative merits may
appear plainly.

Anesthetizaiion. — Chloroform is here considered as the only
anesthetic to be emplc^yed. When this drug first came into
general use it was regarded by many as a specific for eclamp-
sia, and is so regarded by a few to-day. Series of 20, 1 2,
and of 9 cases, treated by chloroform alone, have been re-
ported without a death. Charpcntier reports 63 cases treated
by chloroforni alone with 7 deaths — a mortality of I 1 per
cent. Hut, on the other hand, the mortality from this treatment
in the Maternite was 50 per cent. The place of chloroform in

DYSTOCIA DUE TO DISEASE, 579

the treatment of eclampsia is now settled. No one would rely
on it alone ; but every one is willing to admit its value as an ad-
junct to other treatment

Diaphoresis and Catharsis. — Eclampsia is the result of some
poisonous matter in the blood, and can not be cured until this
poison is eliminated. The only emunctories available for quick
and effectual action are those of the skin and bowels. No matter,
therefore, what plan of medicinal treatment may be adopted,
diaphoresis and catharsis must also be employed. The action of
the skin may be excited by a hot wet -pack, by hot air or vapor,
or by a hot bath. In private practice the hot wet-pack or the
hot-air bath are the most practicable, and are to be recom-
mended. The injection of normal salt solution into the subcu-
taneous cellular tissue or under the breasts is an indispensable
aid to free elimination by the skin. It seems literally to wash
the blood of its impurities. Free catharsis is produced best by
the use of croton oil, which may be administered in drop doses
upon the back of the tongue, and can therefore be given to a
woman whether she is able to swallow or not. Elaterium in
quarter-grain doses, rubbed up with a little butter, may be
administered in the same manner. If the patient can swallow, a
concentrated solution of Epsom salts is administered, in dessert-
spoonful doses every fifteen minutes, until free catharsis begins.
For the stupor that often succeeds convulsions, and in which the
patient frequently dies from the accumulation of poisonous matter
in the blood, the use of Epsom salts is most suitable. I have
in such cases given as much as sixteen ounces of the con-
centrated solution, in repeated doses, before the bowels began to
move.

Venesection. — Phlebotomy is at present somewhat in disfavor.
The reaction against the indiscriminate use of the lancet has,
however, gone too far. While bleeding in every case of eclampsia
will show bad results, there are many cases in which it rescues
women from impending danger of pulmonary edema and apo-
plexy. Physicians in the country, who have to deal with strong,
full-blooded people, are obliged, in the treatment of pneumonia
in routine practice, to use the lancet. In the same class of people
blood-letting in eclampsia is equally necessary. In a report of
fifteen cases in which bleeding seems to have been the only thing
done, there was but one death. In appropriate cases the vene-
section should be done in time, and not, as recommended from
some sources, only when symptoms of pulmonar}'' edema appear.
The measure is preventive of this accident, not curative.

Morphin. — Older statistics of the morphin treatment for
eclampsia show a death-rate of 57 percent. (Winckel), but lately

5 8o THE PA THOLOG V OF LABOR.

Veit has published his plan of giving morphin in convulsions,
with results so striking as to arouse the attention of the medical
world. In more than 60 cases there were but 2 deaths — a
mortality of only 3.3 per cent., the lowest death-rate yet obtained
by any plan of treatment. This result can only be obtained by
giving very heavy doses of the drug. Veit has injected one-half
grain in each convulsive seizure, and has administered as much
as three grains in four to seven hours, and four and one-half
grains in twenty-four hours.

Qiloral, — This drug has many advocates to speak for it.
Charpentier prefers it above all others, and presents statistics to
justify the preference (114 cases, mortality 3^ per cent).
Winckel recommends it most heartily, and by its use has saved
85 out of 92 cases. This drug, too, must be given in lar^e
doses to be effective. Thirty to sixty grains should be adminis-
tered by enema at a dose, and the physician should not hesitate
to give as much as three drams in the twenty-four hours, or
even more in bad cases.

Veratrum Viride, — The use of this drug is the American
treatment of eclampsia. For the past twenty-five years it has
been extensively employed in different parts of the country.
Feam, in 1871, reported 1 1 cases of his own and 2 cases from
the practice of professional friends treated with very large doses
of veratrum viride. None of the women died of the convulsions,
but one succumbed later to puerperal sepsis. Rushmore has
collected 85 cases of eclampsia treated with veratrum viride,
with 20 deaths — a mortality of 23 J^ per cent. Jewett reported
to the American Gynecological Society, in 1887, 22 cases of
eclampsia treated with veratrum viride. Four of the women died
of the convulsions — a mortality of 18 per cent. In 50 cases of
eclampsia collected by Trimble, veratrum gave much the best
results. In 26 cases treated by this drug there were 3 deaths,
while in the remaining 24 cases there were 6 deaths — a mor-
tality, respectively, of 11.5 and 25 per cent.

The remedial measures detailed above comprise all that
should be seriously considered. The treatment of eclampsia
by antemortem Cesarean section, proposed first by Halbertsma,
has not been successful, and can scarcely be regarded as justifi-
able. Caffein, oxygen, and nitrite of amyl have not been used
often enough to justify an opinion of their worth, and this judg-
ment must be passed also on a number of other drugs recom-
mended from time to time. Pilocarpin is simply mentioned to
be condemned. There is no other treatment of eclampsia that
gives so high •mortality. In the Edinburgh Maternity, where
this drug was employed for a time, the mortality was 66.6 per

DYSTOCIA DUE TO DISEASE, 581

cent Pilocarpin strongly predisposes to pulmonary edema,
which explains the high mortaiity.

In eclampsia during parturition the obstetrical treatment must
receive consideration. As a rule, it is better to avoid inter-
ference with the progress of labor, unless the os is fairly well
dilated. Should eclampsia come on before labor begins at all, or
in its earlier stages, the physician's attention should be confined
to combating the convulsions. Having succeeded in subduing
them, attention may be directed to the delivery of the patient.
It is usual to find that the os has dilated rapidly during the
convulsive attacks. It has been recommended to resort lo
forced delivery (accoitckemeiit force) in all cases of eclampsia
during labor, resorting lo deep multiple incisions, if necessary,
according lo Diihrssen's plan. The advantage of this procedure
has not yet been demonstrated, and is not Hkely lo be. The
necessary operation for the delivery of the woman distracts one's
attention from the treatment of the convulsions, and adds for the
time being a violent source of irritation to the already highly
wrought nervous system. Moreover, by waiting for a brief
period, during which energetic treatment may be directed to the
convulsive attacks, sufficient dilatation of the os may be secured
naturally to permit the delivery of the woman without excessive
violence or without too much loss of time. As soon as the os
is dilated beyond the size of a dollar, delivery may be hastened
with advantage by applying forceps if the head is engaged in the
pelvis, or by perfonning version and extraction by the feet if the
head is not yet engaged, or if the breech should be presenting.

It may be useful for the student to have a scheme of treat-
ment for the average case of eclampsia that he can put into effect
without delay or confusion from considering the relative merits
of the different plans just detailed. The following plan should
be successful in the majority of cases : During the attack itself
administer chloroform. As soon as the attack has pas.sed off.
inject under the skin fifteen drops of the fluid extract of veratrum
viride, and administer by the bowel a dram of chloral in solu-
tion. Place upon the back of the tongue two drops of croton
oil diluted with a little sweet oil. Wring out three or four blan-
kets in very hot water, and envelop the woman's nude body in
them, wrapping one around each limb and covering the trunk
with another, and over all piling as many dry blankets and heavy
coverings as can be procured. Inject by gravitj- under the breast
or breasts a pint or more of normal salt solution, or. if the appara-
tus for subcutaneous injection is not at hand, inject several quarts
of the solution by gravity into the bowel. If convulsions recur,
repeat the veratrum viride in five-drop doses if the pulse is quick

THE PATHOLOGY OF LABOR.

S82

and strong. If the face is very congested and swollen, and the
pulse still remains full and bounding, venesection should be re-
sorted to, withdrawing sufficient blood from the veins to reduce
the tension of the pulse. The chloral may be repeated in the
course of the attack two or three times. If the face is pale
and the pulse rapid and weak, stimulation may be required in the
shape of brandy, ether, or ammonia hypodermatically. If the
convulsions cease and the patient Hes in a stupor, but can be
aroused somewhat and is
able to swallow, concen-
trated solution of Epsom
salts, in dessertspoonful
doses, should be given
every fifteen or thirty
minutes until catharsis is
established.

Shock. — The strain of
labor in a weak woman,
some of the accidents of
parturition, or even forci-
ble attempts to expel the
placenta, may occasion
shock after delivery, with
lowered temperature, leak-
ing skin, and a running,
rapid pulse. Cases of this
sort ha\'c been reported
from compression of the
left ovary in attempts to
expel the placenta by
Crcdc's method, thewomb
being turned upon the
ceni.Y so that the left side
looks forward, and the
ovary is grasped between
the thumb and the uterine
wall, when the hand is
placed on the fundus of the womb in the effort of expression.
The condition calls for the ordinary treatment of shock — heat
externally and stimulants hypodermatically.

Typhoid Fever, Pneumonia, and Other Adynamic Dis-
eases.— These diseases, tliou^h rare complications, do occur in
the prc^'uant woman, and in tlie majority of cases occasion pre-
mature delivery. In typhoid fever this occurs in sixty-five jHjr
cent, of tlic cases, and in pneumonia the proportion is quite as

D.yol

106"
106'

103°
lOff
101'
100°

98°
97"

■

PuUo

Re up.

'if

ftnins in la

(..Ihor

DYSTOCIA DUE TO DISEASE. 583

large. The advent of labor in the midst of these diseases is
usually disastrous to the patient. Profound shock is often de-
veloped ; the. temperature falls abnormally low, even to 95° F.,
and the heart-action may be extremely weak. Active stimu-
lation should be employed during the first stage of labor, and, as
soon as the os is sufficiently dilated, the child should be artificially
extracted as rapidly as possible without serious injury to the
mother, in order to save her the strain of voluntary muscular
effort in the second stage.

Valvular Disease of the Heart. — Mitral disease is the most
serious. Certain statistics show a mortality as high as fifty-three
per cent. As pregnancy advances the heart becomes more and
more embarrassed, and respiration more labored. The most dan-
gerous period, however, is just after the expulsion of the child,
when the circulation is much disordered and an extra quantity of
blood is thrown back upon the heart. It has been noticed that
when the discharge of blood is profuse, cardiac failure rarely occurs.
This clinical observation points to the most successful treatment
in cases of threatened heart-failure, — namely, venesection, — with
the removal of from eight to sixteen ounces of blood, if there is
not much blood lost from the parturient tract after labor. Nitrite
of amyl and nitroglycerin are the most valuable stimulants to
employ during labor and directly after its completion. Digi-
talis should be administered hypodermatically during the first
stage in large doses, and as soon as it is possible to insert the
forceps through the os, or to grasp the child's feet if the head
is not engaged, the infant should be rapidly and, if necessary,
forcibly extracted. Deep incisions of the cervix are of the great-
est value in cutting short the duration of labor and in lessening
the force required in the artificial delivery of the child. With
this plan of treatment the mortality of heart disease in labor will
be much reduced. It has been my fortune not to lose a case,
although charged with the care of a number, some of which were
of the most serious character.

PART V.
PATHOLOGY OF THE PUERPERIUBl

CHAPTER I.

Abnormalities in the Involution of the Uterus after Child4»rth*

An abnormal course in the return of the uterus from the post-
partum condition to the ordinary dimensions and weight of a non-
gravid womb may manifest itself by excess or by deficiency ; there
may be superinvolution or subinvolution.

Superinvolution. — This condition is the result of an abnor-
mal prolongation or an exaggeration of that process by which
the gravid womb returns, after delivery, to the dimensions of a
healthy non-pregnant uterus, in consequence of which the organ
is left, some time after labor, much smaller than in its virgin state.

Sir James Y. Simpson first directed attention to morbid de-
ficiency and morbid excess in the involution of the uterus after
labor. Since his time many writers have called attention to de-
ficient involution ; a smaller number have described the rarer
anomaly of the two — excessive involution. Trommel detected
superinvolution in 29 out of 3000 cases ; Simpson ^ saw it in 22
out of 1300 cases ; Sinclair, ^ in measuring 108 uteri after child-
birth, found in 22 instances a uterine cavity of less than 2]^
in. (5.7 cm.), and Fordyce Barker ^ has declared that he sees from
1 to 3 cases every'^ year, and that in his opinion superinvolution con-
stitutes about one per cent, of uterine diseases. Hansen,^ among
120 nursing women, found 2 with a uterine cavity below 6 cm.

^ A. R. Simpson, " Superinvolution of the Uteras," " Trans. Edinburgh Ol>stet.
Soc," i882-'83, viii, p. 88.

2 ♦* Trans. Amer. Gyn. Soc," vol. iv. This .series of measurements, as well as
others made later by Sinclair and Richardson (•* Trans. Amer. Gyn. Soc.," vols, vi
and vii), are sharply criticiz.ed by Hansen, who declares them to be in great part in-
correct. The criticism is apparently merited.

3 " Trans. Amer. Gyn. Soc," viii, 1883; discussion on Dr. Johnson's paper.

* *' Ueber die puerperalc Verkleinerun^ des Uterus," " Zeitschr. f. Geburtsh. u.
Gyn.," xiii, S. 16.

584

ABNORMALtTtES IN INVOLUTION OF THE UTERUS. jSj

(5-6, S'4 cm., or 2.2, 2,1 in.) respectively at the eighth and tenth
week after delivery. Johnson ' gives an account of 3 cases
which occurred in his practice, and Simpson ' refers to those de-
.scribed by Chiari, Chiarleoni, Jaquet, and Whitehead. A case '
has been reported after abortion.

The etiology of the condition is somewhat obscure. It has
been ascribed to wasting diseases, as phthisis, cancer, etc.; to
anemia from hemorrhage at a previous birth or miscarriage ; to
nervous derangements, as puerperal insanity or chorea ; to over-
lactation ; to a rapid succession of labors ; to local inflammations,
especially those which attack the ovaries and abrogate their func-
tions. The degree to which the superinvolution may occasion-
ally progress is surprising, A. R. Simpson reports a case in
which the uterine cavity measured but y^ of an inch, and a still
greater reduction in the size of the uterus and its appendages
after labor has been reported.

Subinvolution. — Subinvolution may be described as an
arrested or a retarded involution of the puerperal uterus.

Causes of Subinvolution. — There is a difference of opinion in
regard to the exact nature of the changes which occur in the
individual mu.scle -cells during involution of the uterus ; but there
can be no doubt as to the cause of these changes, whatever they
maybe. It is a great reduction of the blood-supply. In a gen-
eral way, therefore, it may be asserted that any condition which
tends to prevent a rapid diminution of the blood-supply to the
puerperal uterus may be a cause of subinvolution. Nature's only
method of decreasing the quantity of blood in the pueqjeral
uterus is by the agency of the contracting muscle-fibers ; there-
fore, it may again be asserted that any condition which interferes
with the contraction of the uterus will be a cause of subinvolu-
tion. It is necessary to make these two broad divisions in the
etiology of hubinvolution, for. although frequently interdepend-
ent, they are not rarely independent of each other. In point
of frequency there should be placed first those causes which pre-
vent the normal decrease of blood-supply to the uterus after
labor. Prominent among these should stand hyperjjlasia of the
endometrium.

Subinvolution by an excess of blood-supply may occasion-
ally be traced to the presence, throughout the uterine wall,
of small fibroids. Other causes, besides the two already given,
responsible for subinvolution, are lacerations of the cervix and
peri-uterine inflammations ; inflammations of the uterine body and

i. 1883.

5 86 PATHOLOGY OF THE PUERPERIUM,

of its lining membrane, usually the result of sepsis ; retention
within the uterus of placental fragments, shreds of membranes,
placental or fibrinous polypi, and blood-clots ; chronic consti-
pation ; displacements of the womb ; premature getting up ; pre-
mature resumption of sexual intercourse ; and anything which
interferes with the return of the venous blood to the heart,
causing a passive congestion of the pelvic organs, as increased
intra-abdominal pressure from abdominal tumors, certain diseases
of the liver, and valvular disease of the heart.

Many examples of subinvolution by the mechanical prevention
of perfect uterine contraction may be observed, as large intra-
mural and submucous fibroids ; unusually large masses of hyper-
trophied decidua that sometimes develop at the placental site ;
the retention within the uterus of considerable portions of the
placenta, or placentae succenturiatae ; large blood-clots ; the dis-
placement of the uterus by a retroversion or flexion of the organ,
or by an overfilled bladder ; peritoneal adhesions from old or
recent inflammatory attacks, involving the serous covering of
the uterus and adjacent parts. One fact stands out clearly
from an observation of such cases : The cause of subinvolution
is always some local disturbance, and not a constitutional de-
rangement. The puerperal state may be complicated by any of
the acute or chronic febrile affections, without the slightest in-
fluence upon uterine involution.^

One exception, however, must be made to this general state-
ment : nervous derangements do influence involution. A. R.
Simpson assigns to puerperal insanity a prominent role in the
causation of superinvolution. On the other hand, a sudden
mental shock, some powerful emotion, may temporarily arrest
involution.

The diag:nosis of subinvolution is easy. The fundus uteri should
be a finger's breadth above the umbilicus on the first day of the
puerperal state, higher than it is directly after birth ; on the
second day, at the level of the umbilicus ; the third day, a little
below ; the fourth day, about the same ; the fifth and sixth days,
two fingers* breadth below the umbilicus ; the seventh, eighth,
and ninth days, three or four fingers' breadth above the sym-
physis pubis ; the tenth, eleventh, and twelfth days, at the level
of or a little below the pubes.^ Hansen, by measurements of
1 20 nursing women from the tenth day until the third month after

1 Temesvary and Backer (**Stuclien aiif dem Gebiet des WochenbeUes '*
** Archiv f. Ciyn.," lid. xxxiii, II. 3, S. 331, 1888) actuaily make the assertion th.'.t
fever favors the involution of the uterus.

^ For an ext«Mi>ive bil^lioprraphy of uterine measurements in the puerperal state see
Scliroeder's " Le'irhucli," Sthed., 1884, p. 230, and Hansen, loc. cit.

ABNORMALITIES IN INVOLUTION OF THE UTERUS. 587

delivery, gives the following as the normal course of involution
from the tenth day of the puerperium until the completion of the
process :

Tenth day (114 measurements)

Fifteenth day (1 19 *•

Third week \ 95 *•

Fourth week f 80 **

Fifth week ( 64

Sixth week ( 56

Seventh week ( 40

Eighth week (31

Tenth week ( 22 *'

Twelfth week (15

({
<t

AVERAGS

INTRA-UTERINK

Measurkment.

Minimum.

Maximum.

)•

. . 10.6 (

cm.

8 cm.

13-5 c«n-

• • 9.9

8.3 "

II. 5 "

. . 8.8

((

7.5 "

10.5 "

. . 8.0

((

7.0 "

9.3 "

- • 7-5

(«

6.5 •*

9.0 •*

. . 7.1

6.2 **

9.1 •«

. . 6.9

6.0 "

8.5 ••

)'•

. 6.7

5.6 "

8.5 "

. . 6.5

5.4 "

7.5 **

)•

. . 6.5

6.0 *«

7-5 "

In two-thirds of the cases Hansen found involution completed
in six to ten weeks ; in one-sixth, not until the last half of the
third month or later ; in again a sixth, within six weeks. The
most rapid involution occupied four weeks. Any great deviation
from the normal course may easily be detected, either by ab-
dominal palpation or by the use of a sound, while along with
the arrest or retardation of involution is usually found a pro-
fuse lochial discharge. Ahlfeld ^ claims that free perspiration
after labor is a valuable sign of firm uterine contraction in the
early part of the puerperal state ; when it fails to appear, he
always looks for uterine relaxation.

Treatment. — The treatment should be directed not so much
toward the symptom (subinvolution), as toward its cause. It is
evident, therefore, that the treatment of this condition must vary
greatly in individual cases. If the subinvolution depends upon
the retention of hypertrophied decidua, a curet will promote
rapid involution more effectively than anything else. If placentae
or membranes are retained /;/ utero, they should be removed. If
involution is retarded by the presence of fibroids, the adminis-
tration of ergotin, strychnin, and quinin in pill form, and the
application of a faradic current have given good results. The
bladder should never be allowed to remain distended with urine
nor the rectum with feces. Inflammation in or about the uterus
must be combated by appropriate treatment. If the heart-valves
are imperfect or the heart-muscle weak and the abdominal and
pelvic veins are consequently engorged with blood, a heart-
tonic, as digitalis or strophanthus, will often assist involution.
Charpentier has asserted that the routine administration of ergot
in the puerperal state hastens involution. This would seem

^ ** Der Zusammenhan::; zwischen Schweisseruption postj^artum und Uteruscon-
tractionen," ' Ber. u. Arbeit, a. d. Geburts. Gynak. Klinik zu Marburg," l885-'86,
Bd. iii, S 81.

588 PATHOLOGY OF THE PUERPERIUM.

reasonable, but clinical experience has not borne out the state-
ment.

Herman and Fowler^ did find, in experimenting on two sets
of patients, — one, 58 in number, receiving an ergot mixture
daily for a fortnight after labor ; the other, 68 in number,
receiving a single dose of ergot after labor, — that in the first
set involution advanced more rapidly, but that there was no
difference in the lochial discharge. BoxalP also declared him-
self in favor of the routine practice of giving ergot during the
puerperium, asserting that in two series of cases, comprising
each 100, — one treated without, the other with, ergot, — there
were fewer blood-clots ; these were more quickly discharged,
and the after-pains were less frequent, of shorter duration and
diminished intensity in the latter series. Dakin,^ however, dis-
sented from these views, and claimed, likewise, after testing the
matter in practice, that the routine administration of ergot re-
tarded the involution by at least twenty-four hours. Blanc* also
declared that the administration of ergotin during the first five or
ten days of the puerperal state has not a favorable influence upon
involution, but seems to interfere with it to some extent. As it
is doubtful, therefore, whether ergot does aid involution, as there
are many obvious disadvantages connected with its routine ad-
ministration in the puerperal state, the adoption of the practice
would be unwise, and is not to be recommended.

Puerperal Anemia. — This condition might not inaptly be
called a subinvolution of the blood. After the first twenty -four
hours of the puerperal state there begins a change in the consti-
tution of the blood by which it is converted from the hydremia
of pregnancy to the normal proportion of its constituent parts in
the non-gravid woman. At the end of two weeks the process is
so far complete that the blood is more nearly in a normal condi-
tion than it was during pregnancy.^ Many causes, however,
may disturb the recovery from the hydremia of pregnancy. Ill-
ness of any kind during pregnancy, hemorrhage during labor,®
nervous affections — as insanity or chorea — during the puerperal
state, kidney disease, fevers, etc., may all induce puerperal

1 " On the Effect of Ergot on the Involution of the Uterus," " British Med.
Jour.," 1888, i, 299.

a Ibid. » Ibid. * " Ann. de Gyn6c..'* March, l8S8.

* Meyer, '* Untersuchungcn Ubcr die Veranderung dcs Blutes in der Schwanger-
schaft," •' Archiv f. Oyn.,'' l>d. xxxi, S. 145.

^ It is extraordinary, however, to see how rapid occasionally is the recovery of
puerpene, even from severest hemorrhage. A loss of 2000 to 2500 gnuns (4.4 to 5.5
l>ounds) of blood is usually fatal to an adult, but Ahlfeld reports two cases in which,
respectively, 2000 and 2500 grains of blood were lost without serious anemia after-
ward (" lier. u. Arb. a. d. Geb. Gyn. Klinik zu Marburg").

ABXORM.IL/T/ES f.V INVOLUTION OF THE UTERUS. 589

anemia. The treatment of the condition must be governed by
the circumstances of the individual case. The cause of the anemia
being removed, the blood will improve, and the improvement
may be accelerated by tonic drugs and good diet, After hemor-
rhages, beef-tea, animal soups, and as nutritious a diet as the
patient can bear, along with tonic medicines, will hasten recovery.
By the use of Hlaud's pills I have seen the blood- corpuscles
rise from less than three to nearly four and a half million per
cubic millimeter, and the hemoglobin increase from forty to
seventy-five per cent, in a few weeks. In some cases arsenic
alone succeeds where iron fails. Osier • has reported an inter-
esting case of the kind.

Repair of the Injuries of Child-birth. — Slight cracks in the
mucous membrane, small rents in cervi.x, vaginal wall, and vagi-
na! outlet. — unavoidable occurrences in almost every labor, —
either unite firmly or else are healed by granulation. Occasionally,
very extensive injuries are rcjjaired by natural processes. Per-
forations of the vaginal vault, fistulous ofx:nings into bladder and
rectum, deep tears and perforations of the perineum, transverse
■ rents and perforations of the labia, lacerations about the urethra, —
all have been known to unite without interference. Winckel
states that perineal tears, when left to themselves, will be found
healed in two and a half to five weeks. Extensive injuries, how-
ever, should be repaired, wherever practicable, by sutures. Rents
in the vaginal mucous membrane and cervical tears do not usu-
ally require this treatment, unless there is profuse hemorrhage.
Lacerations of the perineum, of the pelvic floor, and of the
vaginal sulci should never be neglected. If the stitches are in-
serted carefully, primary union is almost invariably secured. In
fistul.'e the result of .sloughs after labor, if the opening be not
too large, a cure can occasionally be effected by touching the
edges of the fistula with a strong caustic, like nitric acid. To do
this the diagnosis mu.st be made in the lying-in period, which,
as a rule, is not difficult. The escape of feces and gas from the
vagina, and a constant trickling of urine, point respectively to a
rectovaginal or a genito-urinary fistula. It is necessary in the
latter case to exclude the incontinence of urine due to paresis of
the vesical sphincter, and the overflow of retention sometimes
seen in the puerperal slate. All doubt is cleared away by find-
ing the anomalous opening between bladder or ureter and vagina
or cervical canal. In abrasions and wounds along the parturient
tract it is necessary occasionally to apply lint saturated with car-
bolized oil to prevent an acquired atresia of the birth-canal. If

Boston Med. and Surg. Jou

590 PATHOLOGY OF THE PUERPERIUM,

the abrasions and wounds are infected and covered with exudate
they should be cauterized with nitrate of silver solution, 3J-f^.

Edema of the external genitals, the result of injuries, pres-
sure, or contusions during labor, gives rise to considerable pain
and discomfort, which are best relieved by the application of
cloths wrung out in a hot sublimate solution, i : 4000. The
influence of injuries in the genital tract upon the course of the
puerperal state is unfavorable. The danger of septic infection is
materially increased, and fever is consequently more common,
not only from this cause, but as a direct result of the injury and
irritation of tissue.

Retention of urine is another consequence of injury to the
vagina during labor, according to Winckel^, who says that he
has seen obstinate cases of retention, lasting from ten to four-
teen days, due to this cause.

Puerperal Hemorrhage. — The term " puerperal hemor-
rhage " is used to denote profuse bleeding from any point along
the genital tract of the female, occurring after the first day of the
puerperium until involution of the uterus is completed — a period
of about six weeks.

The causes of this accident are numerous and should be well
considered, for the treatment is governed in most cases by a
knowledge of the cause. The causes are placed as far as possible
in the order of their frequency.

Retained Placenta and Membranes. — The retention within
the uterus of the placenta, as a whole or in part, will very likely
give rise to hemorrhage during the puerperal state. The retention
of the whole placenta is not now a cause of puerperal hemorrhage,
for no practitioner of the present day would allow this large mass
to remain within the uterus many hours after delivery. Toward
the end of tlie last and in the beginning of the present centur>',
however, it was not rare to find followers of William Hunter, who
trusted altogether to nature to deliver the placenta, often with
most disastrous results. White ^ gives an account of four cases
of retained placenta, with fatal hemorrhage occurring on the first,
second, third, and fourth days, respectively.

The retention of placental fragments is by no means rare.
A careful inspection of the placenta after delivery often shows
a defect, and the missing piece must be sought for and re-
moved ; but occasionally it is difficult or impossible to tell
whether the placenta has come away entire ; and if the retained
portion is an accessory growth, there is, of course, nothing to

^ •' Lchrbuch dor Ciclmrl.^hulft'," ]). 741.

-**A Tn-atise on ihe Management of Pregnant or Lying-in Women,'*
Worcester, Mass., 1793. V- -^'5-

PUERPERAL HEMORRHAGES. 59 1

indicate its existence in the appearance of the placenta proper.
Stadfelt states that, in 70 examinations of puerperae postmortem,
placental fragments were found in 7 cases, varying from the size
of a hazel-nut to that of an ^SL'g, Clinical observation alone
makes this complication of the puerperal state appear more rare.
Of 2960 births in the Frauenklinik at Munich, from 1884 to 1887,
there were reported 9 cases of retained placental fragments. ^ It
is possible, however, that small portions of placental tissue might
escape unnoticed in the lochia! discharge, or else by their dis-
integration form a part of the discharge. The retention of pla-
cental tissue in utero does not always cause hemorrhage. I have
seen a placenta succenturiata expelled on the second day of the
puerperal state without any previous bleeding, and a very large
piece of the placenta discharged four days after a premature
birth, very fetid, but with no bleeding. In the 9 cases reported
by Martini there was a prolongation of the bloody lochia in i, a
severe hemorrhage in 2 ; in 6 there was no excessive loss of blood.

The cause of the retention of placental fragments is either
some abnormal form of placenta (marginata, multiloba, suc-
centuriata, etc.), an abnormal adhesion to the uterine wall, or too
forcible or premature efforts at extraction or expression.^

Retention of the membranes after labor is of frequent occur-
rence. Martini reports 71 cases out of 2960 births.^ Reihlen*
found a retention of some portion of the chorion in 152 out of
3534 labor cases (4.3 per cent.). Another investigation gave
5.1 percent, from an analysis of 11,381 births. Crede ^ reports
91 cases of retained chorion in 2000 births.

Membranes letained /// titcro may give rise to septic infec-
tion ; whether or not they are a cause of puerperal hemorrhage is
still a disputed question. Crede ^ has expressed his belief that
retention of the chorion is not at all dangerous. Olshausen has
declared that the retention of the chorion should never justify
interference to extract it.*^ Reihlcn ® says that he never saw
hemorrhage as a result of retained chorion. Schroeder ^ asserts

^ Martini, **Ueber das Zurilckbleil^en von Eihaut u. Placentarresten bei vor- u.
rechtzeit. Geburt," ** Milnchen. med. Wochenschr.," 1888, p. 653.

2 Ahlfeld in 996 deliveries saw only 4 cases of puerperal hemorrhage. He
attributes the freedom from this accident in his clinic to his conservative manage-
ment of the third stage of labor. He insists upon waiting one and a half hours be-
fore expressing the placenta (** Ber. u. Arbeiten," Marburg, Bd. iii).

• Loc, cit.

*"Zur Frage der Behandlung der Chorion- Retention," "Archiv f. Gyn.,"
Bd. xxxi, S. 56.

« **Archiv f. Gyn., Bd. xvii, S. 278. « Loc. cit.

f " Klin. Beilr. zur Gyn. u. Geburtsh.," 1884, S. 146.

» Loc. cit. 9 '* Lehrbuch," lo. Aufl., 797.

594

PATHOLOGY

resistance must be
serting one finger, then two, .
To accomplish the dilatation
an anesthetic.

If puerperal hemorrhafjc
or placental fraymtnts wilhi

fig. 4S3-— ■'^l"t''i 'eciioQ of
heart withiti an liour after deliv
e, uterovesical rpfieelion of perilon
C. prumonloiy of sacrum ; h, poncM

and their removal should h

dition is clearly seen to be I
the uterine cavity after invofl
prof^rcss, it is often necej
Hej^ar's boiiijicH will be foJ
instruments lor the puqjoi

ss:;?^;

^"^^^t.;

1kJ«

PUERPERAL HEMORRHAGES, 593

amount of blood to the whole organ, with the same result.
Even a small portion of deciduous membrane, as well as shreds
of adherent chorion and amnion, or placental fragments, may
form the foundation of polypoid tumors reaching occasionally
considerable size, composed chiefly of firmly clotted blood or
fibrin. The growth of these bodies is like stalactite formations
on stone. The same thing occurs in difierent shape when the
placental site is left unusually rough and vascular. The blood
oozing from the sinuses may deposit successive layers of fibrin
until quite a thick mass is formed.

Diagnosis aiid Treatmeiit, — The fact that a portion of the
ovum has been retained /// utero is usually easy to discover. A
careful examination of the secundines after labor enables one
to detect missing parts, which must have remained behind in the
genital tract. It is not wise, as a rule, to invade the internal
genitalia in order to remove small shreds of amnion and
chorion ; if, however, a greater part of these membranes has
been retained, it is advisable to remove it. The diagnosis of re-
tained placenta is, as a rule, easy. When the whole organ re-
mains /// uttro, the cord dangling from the external genitals points
clearly enough to the condition. If one or more cotyledons
remain behind, their absence may be noted from the placenta
after its delivery. Occasionally, the diagnosis is more difficult,
even if the whole placenta is retained. I recall a case in which a
woman was delivered on her feet ; the child dropped to the floor,
the cord was dragged ofi* from the fetal surface of the placenta,
and the latter remained behind in the uterus ; it was tightly
adherent to the uterine wall, and its discovery, with no cord to
guide one, was by no means an easy matter. It was finally
peeled off* and extracted, the woman meanwhile bleeding
furiously.

Cotyledons torn off* the periphery of the placenta may easily
go undetected, and in certain roughly lobulated placentae it is
very difficult to be sure that no placental tissue has remained
behind.^ If the medical attendant suspects the retention of
placental masses after labor, he must attempt their removal. This
is usually not difficult. The hand — the only trustworthy instru-
ment under the circumstances — is inserted into the uterine cavity,
the placental substance is felt for, caught by the fingers, and
removed ; if the placenta is adherent, the tip of the finger must
be gently inserted, wherever most practicable, under the edge,
and the whole organ gradually peeled off". If the uterine muscle
is too firmly contracted to allow the introduction of the hand, the

1 " Zur Frage der Behandlung der Placentar- Retention," etc., " Zeitschr. f.
Geburtsh.,*' xvi, pp. 292, 302.

TOCV OF THE PUERPERIl^^.

resistance must be overcome bj' firm, gradual pressure, first in-
serting one finger, then two, and so on until dilatation is effected. J
To accomplish the dilatation it is often necessary to administer I
an anesthetic.

If puerperal hemorrhage occurs, the presence of membranes I
or placental fragments within the uterus should be suspected, '

Fig. 453. — SlcBU'i aetlion of a iiriniipata, who died rrom hcmoR^uge «
heart withm bd hour after dclivi-tyt a, a, Contiaclion-hng ; J, b. 01 iotemumi.
<-, ulerove^ical reflcclion of perlioncutii : d, bladder ; t, tymphysis pu^a \ /, urcthrmt J
g, promoDtory of sacrum \ 4, pouch of Douglas 1 1, posterior Aimil ; '

and their removal should be attempted unless some other con-
dition is clearly seen to be the cause of the bleeding. To reach
the uterine cavity after involution and retraction have made some J
progress, it is often necessary to dilate the cervical canal.
Hegar's bougies will be found the safest and most convenient I
instruments for the purpose. Branched dilators, unless used ]

PUERPERAL HEMORRHAGES.

595

with the tjreatest care, arc dangerous in the puerperal womb.
Not rarely, however, the cervical canal remains patulous in con-
sequence of a foreign body in ntcro ; in this case access to the
retained mass and its removal are easy.

Displacements of the Uterus. — The dislocation of the puer-
peral uterus often manifests itself in puerperal hemorrhage,
prolapse, displacements forward and backward and

upward by a distended bladder, are all likely to be followed by
profuse bloody lochia, if not by an active hemorrhage. In-
version and prolapse have already been considered ; retroversion,
retroflexion, and anteflexion are noticed here.

Hemorrhage is likely to occur in these displacements as a
result of the passive congestion always associated with them,
due to interference with the venous circulation; or the bleeding

PATHOLOGY OF THE PUERPERWM.

may be the consequence of the retention of blood williin the
uterine cavity, due to the mechanical interference with its escape ;
in the latter cases clots arc formed, increasing gradually in size.
often undergoing putrefaction, and acting not only as a foreign
body, preventing uterine contraction, and attracting by their irri-
tating action an extra amount of blood to the uterus, but consti-
tuting as well a favorable nidus for the development of septic
germs, which may extend their operations to the thrombi at the
placental site, disintegrating them. '

The causes of uterine displacements in the puerperal state are
the increased weight of the puerperal uterus, with loss of tonicitj-.
They are, therefore, not infrequently associated with subinvolu-

Wi^ijB^

tion. Backward displacements of tlie puerjieral \\'onib are most
frequently the result of a displacement antedating conception.
They are frequently due also to some sudden physical effort soon
after leaving the bed, especially if the woman has risen too early,
before involution has advanced sufficiently far. Another common
cause is the faulty application of a compress under the binder
Many nurses, unless they are properly directed, place a thick
compress in direct relation with the anterior uterine wall, thus
crowding the whole organ backward, instead of adjusting it
over the fundus of the uterus, where it maintains a condition

a utvriiie diiii>lBC

PUERPERAL HEMORRHAGES.

597

of anteversion, and by constant pressure promotes firm contrac-
tion and rapid involution. Retroversion and retroflexion may

persist after premature delivery, if these displacements existed
during pregnancy. Neglect to empty the bladder at proper
intervals may be found a cause in some cases.

The diagnosis is easy if a careful physical exploration is
made : and it should be an invariable rule to make a careful
vaginal examination in everj' case of puerperal hemorrhage. It
is not rare to find somt; portion of the ovum or blood-clots
retained within the uterine cavity in consequence of the " steno-
sis by angulation " nf the cervical canal.' It is, therefore, not

Webaler's seclion from a cnie of death from eclflmpsitt
rlivery; a. Fundus: h, bladder; c, symphysis pubis;
: /, pouch of Douglas ; g, vagiim.

sufficient to rest satisfied with the diagnosis of displacement in
puerperal hemorrhage, but it is necessary- to be sure that there is
nothing retained within the uterus. It should be remembered
that there may be no hemorrhage, but, for a time, suppression
of the lochia, with displacements of the womb. Occasionally, if
the dislocation occurs acutely, it may be associated with grave
symptoms, as intense pain, a condition verging on shock, and
high fever, these symptoms disappearing immediately upon the
reposition of the womb.

' Femley, "Brilish le." Jour," |8S8, ii, 739.

59^ Pathology of the puerperium.

The treatment of puerperal hemorrhage due to a displaced
uterus is the rectification of the displacement, which is occasion-
ally followed by the expulsion of blood-clots or remains of the
ovum imprisoned within the uterus, and the true causes of
the bleeding.^ The uterus, restored to its natural position,
should be retained there, for a while at least, by mechanical
support.

Dislodg:ment and Disinteg:ration of Clots at the Placental
Site. — ^The thrombus formation in the large sinuses at the pla-
cental site plays a subordinate part in the prevention of hemor-
rhage after delivery. In consequence of sudden exertion, sitting
upright in bed, or actually standing on the floor soon after
labor, some of these clots, plugging up important vessels, might
be dislodged. It is with this possibility in mind that every pre-
caution should be taken to secure quiet and repose for the
woman after labor. Disintegration of the clots at the placental
site occurs occasionally in consequence of their invasion by
micro-organisms. This is, therefore, one of the phenomena of
puerperal infection. The bleeding that follows is, of all puer-
peral hemorrhages, by far the most dangerous.

Diagnosis, — The hemorrhage that follows displacement of
thrombi at the placental site is startling in its suddenness, and
alarming in the amount of blood lost. There need be nothing
in the uterine cavity to account for it ; the uterus may be in good
position. The true condition can, of course, only be inferred.

Treatment. — The best treatment for this kind of uterine
hemorrhage is thus described by its author. ^ He takes with him
to every case of labor a strip of twenty per cent, iodoform gauze
three yards long, two hands' breadth in width, in four layers. On
this is scattered loose iodoform powder. To tampon the uterus
the anterior lip of the cervix is .seized as high up as possible with
two bullet-forceps ; the strip of gauze is then caught by the end
in a long pair of forceps and is introduced within the uterus. As
soon as the point of the forceps enters the uterine cavity the left
hand grasps the fundus, and only then is the forceps pushed in
as far as it will go. The forceps is then loosened, withdrawn a
little, a lower portion of the gauze strip is seized, and so the
uterus is filled with gauze, lying in fan-shaped folds. ** It is
astonishing," says Diihrsscn, ** how soon the uterine cavity is
filled." The uterus is stimulated to contraction ; so one gets the

' Strachan reports an interesting case of the kind associated with anteflexion.
Six weeks after labor there was a severe hemorrhage; the uterus was straightened by
upward ])ressurc through tlie anterior vaginal vault. The following day a cotyledon
of the placenta was discharged (" British Med. Jour," 1886, i, 587).

' I)iihrssen, ** I)ie Uterus-Taniponade "I't lodoform-Gaze bei Atonie des Uterus
nach nornialcr (ieburt,'' *' C.Vntralblalt f. C '" 1887, xi, 553.

PUERPERAL HEMORRHAGES. 599

combined advantage of a tampon and a uterine stimulant. When
the gauze is removed, it has very few blood-clots in it, and has not
a trace of putrid odor.

Every one who has ever used extensively the intra-uterine
tampon for hemorrhage will attest the statement that it is of
inestimable value. There xs no other means so absolutely sure
to check uterine bleeding.

Emotional Causes. — Sudden emotion of any kind arrests
uterine contraction during labor and in the puerperal state.
In the latter condition the usual result is a hemorrhage, which
may be alarming. Barker ^ gives an interesting example : A
healthy young primipara almost bled to death in the second
twenty -four hours after labor in consequence of the brutal con-
duct of her husband, who was disgusted that his child was a girl.
I have seen a sudden and profuse hemorrhage on the seventh
day, the result of fright. The patient's step-son returned home
late at night in a violent state of intoxication.

Relaxation of the Uterus. — This is a rare cause of hemor-
rhage after the first twenty-four hours. It is scarcely ever seen
later than the third day, and when it occurs after the first twenty-
four hours it is in women depressed in mind and body, exhausted
by prolonged labor, weak from insufficient food or bad hygienic
surroundings. It is to be treated on the same general principles
as a primary postpartum hemorrhage from the same cause.

Retention of Blood-clots. — This is usually the result of
uterine relaxation, uterine displacements, or a retention of por-
tions of the ovum, around which the clot is formed. If these
conditions are promptly treated, the retention of blood-clots will
be prevented. The effect of a clot of large size retained in utero
is often a hemorrhage, possibly also septicemia. The mass of
clotted blood should be removed as soon as the symptoms lead
the medical attendant to suspect the presence of a foreign body
within the uterus.

Fibroids. — If the puerperal state is complicated by intra-
mural or submucous fibroids of the uterus, there are certainly a
prolongation and an increase in amount of the bloody lochia, pos-
sibly a serious hemorrhage. The latter is peculiarly liable to
happen if the tumor assumes the shape of an intra-uterine polypus.
The diagnosis is only to be made by a careful physical explora-
tion. The best treatment is the removal of the growth by scissors
after ligature of the base, or with the wire ecraseur. In case this
treatment can not be carried out, and in other forms of fibroid
tumors in the puerperal state, ergotin, with quinin and strychnin,

^ "The Pueqje* )iseases," p. 15.

600 PATHOLOGY OF THE PUERPERIUM.

and the daily application of the faradic current, if practicable, do
much to secure firm uterine contraction and prevent hemor-
rhage.

Hematomata. — Blood-tumors along the genital tract may
burst during the puerperal state, with most serious external
hemorrhage. The condition is described elsewhere.

Pelvic Eng^org^ement. — Congestion of the pelvic blood-
vessels may lead to puerperal hemorrhage. The congestion
may be due to heart, kidney, or liver disease ; to increased intra-
abdominal pressure from any cause ; to the determination of
blood toward internal organs during a chill ; ^ to premature sex-
ual intercourse ; to the erethism following the return of the hus-
band to the wife's bed ; to inflammation about the uterus ; to
subinvolution from any cause ; to ovarian irritation, and to con-
stipation. Mauriceau ^ describes a case of puerperal hemorrhage
that continued quite profusely for five or six days, and which
was only checked when ** a pretty strong clyster " resulted in the
evacuation of ** a panful of gross excrements."

Wounds in tlie Genital Tract. — Secondary hemorrhage may
occur from wounds in the cervix, vagina, and vulva. Occasion-
ally, abnormally large blood-vessels are injured in these regions.
On one occasion I saw a hemorrhage from an anomalous artery
in the perineum that nearly proved fatal. It is possible that a
vessel of considerable size might be wounded during labor, and
yet, in consequence of pressure from the child's head or of an
unstable plug of clotted blood, would not bleed until, at some
time in the puerperal state, the tissues recovering their tone or
the clot being dislodged hemorrhage would occur.

The diagnosis is easily made if the parts are exposed to view.
The bleeding vessel may be detected and should be ligated.

Carcinoma of the Corpus Uteri and of the Cervix. — Carci-
noma (syncytial) or sarcoma may develop at the placental site
during the pucrpcrium. Epithelioma of the cervix, if at all ad-
vanced, will surely cause some hemorrhage. The best treatment
for the immediate control of hemorrhage from this cause would be
a uterine or a vaginal tampon. Vaginal hysterectomy should be
performed, if possible, without delay. Fritsch has shown that
the operation is perfectly practicable immediately after labor.

As rare causes of puerperal hemorrhage might be mentioned
rupture of the uterine artery, as occurred in a case reported by

^ Winckel (*' Path. u. Therap. dcs Wochenl).'") rejwrts 4 cases of this kind out
of 1 14 of piier])enil hemorrhage. I once observed a striking example durinij a
malarial attack some days after lal>or.

^ ** Diseases of Women with Child and in Child-bed," translated by Hugh Cham-
berlen, IxDndon, 1 752.

PUERPERAL HEMORRHAGES. 6oi

Hewitt,^ with a fatal result six weeks after labor ; the rupture of
a distended vein in the cervix, followed by fatal bleeding, as hap-
pened in a case described by Hecker.^ Meschek ^ reports a
similar case, with like result, due to an eroding ulcer which
opened a large vessel in the cervix. Johnston has reported a
fatal puerperal hemorrhage due to rupture of a hematoma of the
cervix. "*

Puerperal Hematoma. — A form of hemorrhage in the female
genitalia during or after labor, much more rare than the second-
ary hemorrhages just described, is an interstitial effusion of blood,
with the consequent formation of a blood-tumor, varying in size
with the degree of the hemorrhage. Levret seems to have been
familiar with the accident, but with this exception a knowledge
of the nature of hematoma in puerperae has been acquired in quite
recent times. The first systematic treatise on the subject is
Deneux's monograph.^ It was also fully described by Dewees.^

The accident is of rare occurrence, but individual experience
differs widely as to its frequency. Deneux was able to collect
62 cases, but had himself only seen 3 in a practice of four-
teen years. Paul Dubois saw but i case in 14,000 labors.
Velpeau,*^ writing five years after the appearance of Deneux's
article, declared that it would be easy to collect the detailed ac-
counts of 100 cases; that he himself had seen 25. Barker, of
New York, reported 22 cases that came under his personal
observation. Winckel quotes McClintock's claim that he had
observed 25 cases, and places an exclamation mark after the
quotation, evidently as a sign of incredulit>'.* The former has
only met with 6 well-marked cases in an experience of almost
20,000 confinements. Bossi found hematoma ta twice among
5660 women in child-bed ; Hugenberger, 1 1 times in 14,000
deliveries;^ in Vienna it was noted 18 times out of 33,241
births.^® This would indicate a frequency of i to 1600 births.
I have seen two cases in twelve years.

The situation is most frequently, by far, in one or the other
labium majus, rarely in both. The blood-tumor may, however,

^ "London Obstet. Trans.," vol. ix. 2 i» Archiv f. Gyn.," Bd. vii, S. 2.

« " Zeitschr. d. Ges. d. Wien. Aerzte," 1854. x.

* Sinclair, «' Pract. of Midwifery," 1858, p. 501.

' *• Tumeurs sanguines de la Vulve et du Vagin," Paris, 1 830.

•"Midwifery."

' */ Traits complet de I'Art des Accouchements," Brussels, 1835.

» ** Lehrbuch der GeburtshUlfe," 1889.

® ** Hseniatoma Vulvae imVerlauf der Schwangerschaft," "Archiv f. Gyn.," Bd.
xxxiv, H. I.

* ** These latter statistics are taken from Winckel's lx)ok, where a reference to the
original authorities may be found.

602 PATHOLOGY OF THE PUERPERWM.

occupy a position beneath the vaginal wall, to either side, pos-
teriorly or anteriorly in the labia minora ; in the carunculae
myrtiformes ; under the skin of the perineum, between the super-
ficial and median fascia ; in the cervix ; in the peri-uterine con-
nective tissue ; within the broad ligament ; in the subperitoneal
connective tissue, on the posterior and anterior abdominal walls,
extending as high as the kidneys and navel (Cazeux, Hugenberger,
Winckcl) ; under the skin of the mons veneris or over the in-
guinal ring (Velpeau). If the effusion occurs above the pelvic
fascia, the blood forces its way upward toward the diaphragm ;
if below, downward toward the vulva.

Size and Form. — Small extravasations of blood are to be met
with along the genital tract very frequently after labor ; this form
of thrombus is due to the fact that the mucous membrane is
pushed in front of the presenting part with a glacier-like move-
ment over the underlying tissues, and there thus occurs a rupture
to some degree of the submucous connective tissue and the small
blood-vessels contained in it. On a careful examination one may
often see numerous hematomata after labor, varying in size from
that of a pigeon's ^^^ to that of a walnut. It is the larger
tumors that are rare. They may vary in size from that of a
hen's ^^^ to that of a child's head ; in extreme cases, if the
blood is diffused throughout a great part of the subperitoneal
connective tissue, the size of the effusion would be very large
were the blood contained within a limited, circumscribed tumor.

In shape, blood-tumors of the genital tract may be globular;
in the cervix they distend the tissues of one or both lips down-
ward and outward, giving to the cervix the form of a shark's
nose. In the vagina they may hang from the anterior or posterior
wall in the form of a polypus (Heischmann). In the labia the
hematoma is sausage-shaped (see Plate 9).

Etiology. — The predisposing causes of puerperal hematomata
are the engorged condition of the blood-vessels along the genital
tract and the strain that is imposed upon them either by the
pressure of the fetal mass or by the great muscular effort put
forth during labor. The more engorged the ves.sels are, the
more likely is the occurrence of hematoma. Winckel says it is self-
evident that varicose veins predispose to the accident. Barker,
however, denies this emphatically. It is certainly true that many
a case of varicose veins may be met with before a hematoma is
seen, and in many instances of the latter the veins were in no-
wise affcctecl. Ifalliclay Crooni ^ attaches great importance to
antevcrsion of the parturient uterus as a predisposing cause

' "On the Ktiolo^) of Vaginal Hematoma Occurring During Labor," ** Edin-
burgh Med. Jour.," vol. xxxi, pt. ii, p. looi.

^M 3 Btdb. waijkingls^

HeraaWnm of llie vulva (iiulhor'i (.-ase),

i H

■Et

PUERPERAL HEMORRHAGES. 603

of vaginal hematoma, believing that thus an excessive strain is
put upon the whole posterior vaginal wall, and a rupture of dis-
tended blood-vessels in this region is therefore more probable.
This explanation seems reasonable, but it leaves unexplained
the hematomata in other situations along the birth-canal.
Hypertrophic elongation of the cervix certainly predisposes to
the formation of hematomata in that region during and after
labor. The determining cause of the accident may occasionally
be found in direct injury to the tissues by forceps, and rarely by
a fall or a blow, or it might be explained by violent straining
efforts during the second stage of labor. In the majority of
cases, however (eighty-six per cent., Winckel), the occurrence of
hematomata is apparently spontaneous. The immediate cause
of the hematoma is the rupture of a blood-vessel and the inter-
stitial extravasation of blood ; the vessel injured is commonly a
vein, not rarely of large size. Possibly a number of smaller
vessels may be ruptured. The injury to the blood-vessels is
either a direct and immediate laceration or else, later, a perfora-
tion by pressure necrosis.

Clinical History and Dias:nosis. — The interstitial hemorrhage
that results in a hematoma begins, with rare exceptions, during
labor. The extravasation of blood may at first be gradual, so
that it does not attract attention until some time in the puer-
peral state. The distention of the vagina by the presenting part
of the fetus may prevent all bleeding until the maternal tissues
are relieved of pressure. If the bleeding results from necrosis
of tissue, the result of prolonged pressure, the formation of a
hematoma may first begin after delivery. In cases in which the
accident has seemed to be the result of violent coughing or other
exertion during the child-bed period, there had been, no doubt,
some injury done the vessels during parturition. The sub-
cutaneous or submucous laceration of tissue occurring, as a rule,
during the second stage of labor is almost always associated
with great pain of a sharp, lancinating character, quite different
from labor-pains. The suffering increases as the hematoma
grows in size, and, in addition to the sharp pain of torn tissue,
there is developed exaggerated and painful expulsive efforts
excited by the presence of the tumor within the vagina. This
i^ a symptom almost constant, but Barker tells of a painless
case, and says that his is not the only one recorded. The
hemorrhage into the tissues may be profuse enough to occasion
the most marked signs of acute anemia. Pallor of the coun-
tenance, failure of vision, a thready pulse, air-hunger, loss of
consciousness, and, finally, death, may all be noted without
the slightest external escape of blood. An examination of

604 PATHOLOGY OF THE PUERPERIUM,

the patient shows a tumor occupying the situations already
described, of varying size, and differing in consistency as the
blood contained in it is fluid or clotted. If the hematoma is
submucous, it presents a dark, purplish color, like clotted
blood. If it is covered with skin, it presents a bluish, ec-
chymotic hue, although in the labium majus the color may be
the same as in a submucous hematoma. As a rule, the swell-
ing only appears after labor. It may, however, occur before
the expulsion of the child, and it has repeatedly devel-
oped between the birth of twins. ^ If the tumor is formed
during labor, it may present a formidable obstacle to delivery ; if
it appears in the puerperal state, it may dam back the lochia or
give rise to dysuria or to retention of feces. With the history
of a sharp attack of pain during labor, the subsequent rapid de-
velopment of a tumor along the genital tract characteristic in its
appearance and situation, the signs of internal hemorrhage, the
diagnosis of the true condition ought not to be difficult ; and yet
a mistake is quite possible.

Puerperal hematoma has been confused with varicose tumors
of the labia, inguinal hernia, and inversion of tlu tfagina. Once
in Barker's experience a vaginal hematoma was mistaken for a
fetal head, and once for placenta prctina, Auvard^ says that on
first sight he took a hematoma o f the anterior lip of the cervix
for a clot of blood lying in the vagina. The Barneses,^ in
describing their case of cervical hematoma, write that they found
a fleshy tumor projecting from the vulva which looked like a
mass of coagulated blood, or which might have been mistaken for
an inverted uterus. The diagnosis seems to be more difficult in
cervical hematoma than in tliose lower down in the genital
canal. Luckily, the former arc rare. Besides the two just
mentioned, others are described by Hohl, Braun, Earle (two
cases), and Winckel.'* Hematomata along the genital canal may
burst soon after their formation, with appalling hemorrhage,
which may rapidly prove fatal. In cases of labial tumors the
point of rupture is likely to be the boundary-line between the
greater and lesser labia. A hematoma within the f)elvis may
open into the peritoneal cavity, with fatal hemorrhage. In one
case under my observation a large hematoma formed between the
layers of the broad ligament. Four hours later the posterior

^ One case re|X)rte(l by Dewees (*' Diseases of Females," "Of Bloody Infiltra-
tion in the Labia Pudondi "), and six by Madame Sasanoff ("Annales de Gyne-
cologic," December, 1884). Four of these latter cases died.

2 «' Trav. Obstct.," Paris, 1S89, t. i, p. 449.

3 "System of Obstetric Med. and Surg.," Philadelphia, 1885.
* *♦ Lehibuch," 1S89.

PUERPERAL HEMORRHAGES, 605

layer of the broad ligament ruptured, the bleeding became intra-
peritoneal and unlimited, and the patient died before I reached
her. After early rupture or primary incision of the tumor, the
hemorrhage will almost surely be great, and secondary bleeding
is apt to occur. This accident does not happen, as a rule, when
the tumor is opened after bleeding into it has ceased.

Winckel has thus summarized the terminations of puerperal
hematoma : ( i ) Death by hemorrhage with or without previous
rupture of the tumor ; (2) death following suppuration of the sac
and septicemia, most frequently after the sac has been opened ;
(3) rupture of the tumor, with recovery ; (4) rupture of the
tumor, with a resulting fistula; (5) perfect recovery by absorp-
tion of effused blood, without rupture of the sac. In fifty cases
collected by Winckel from modern literature the tumor burst
spontaneously in the first eight days in twenty-three. A hema-
toma may be evacuated not only by escape of the contained
blood externally, but by diffusion of its contents under the skin.
Diin reports a case of large hematoma of the right labium,
which burst and at the same time occasioned ecchymoses reach-
ing to the nates and to the right knee, to the umbilicus, and even
as high as the right axilla. Suppuration may occur in a blood-
tumor that has not been ruptured at all, and the effused blood
may be converted into a large accumulation of pus. As these
abscesses are often in the neighborhood of the rectum, the pus
often acquires a fecal odor, even without a communication with
the bowel. A rectovaginal fistula may result if the hematoma
breaks its way into the rectum and also opens anteriorly into the
vagina. Suppuration is most to be feared after the blood-tumor
is opened and its cavity is exposed to the contamination of the
atmosphere and of the lochial discharge.

Prosrnosis. — The formation of a hematoma during or after labor
was formerly regarded as a more dangerous complication than it
is considered to-day. Of Deneux's 62 cases, 22 died. Fatal
cases have been reported by Cazeaux, Lubanski, Broers, Seulen,
Josenhans, Hugenberger, Braun, and the author. The causes
of death in these cases were hemorrhage (in two instances into the
peritoneal cavity), septicemia, and typhoid fever (?). Blot col-
lected 19 cases since Deneux's paper was published, with 5
deaths. Perret, in an analysis of 43 cases, found 17 deaths. Of
II cases observed by Hugenberger, ^ 4 died. Girard,^ in an

> " Dublin Jour. Med. Sci ," November, 1886.

« "St. Petersburg med. Zeitung," 1865.

' ** Contribution ^ I'itude des Thrombes de la Vulve et du Vagin dans leurs
Rapports avec la Grossesse et 1' Accouchement," *' Thise de Paris," 1874.

6o6 PATHOLOGY OF THE PUERPERIUM.

analysis of 120 cases, found 24 deaths. Johnston and Sinclair^
report 7 cases during seven years' service in the Dublin Rotunda,
with 2 deaths. Scanzoni met with 15 cases, i of which died.
Winckel, among 50 cases, found only 6 deaths. Of the 6 cases
in his personal experience, not one died. Barker reports 22 cases
of his own, of which 2 died. Barnes ^ reports 2 cases with a
favorable issue ; Auvard, ^ i of cervical hematoma that disap-
peared by absorption. Groom's 3 cases all recovered. Death
from a puerperal hematoma at present should be rare, especially
if the patient's general condition is good and her hygienic sur-
roundings are satisfactory.

Treatment. — If the hematoma is of moderate size, not larger
than one's clenched fist, the main object of treatment is to secure
absorption of the effused blood, and thus the disappearance of
the tumor. It may, however, be necessary to remove an ob-
struction to labor if the tumor develops before delivery ; to con-
trol the hemorrhage either before or after rupture of the sac ; to
treat the general symptoms of profuse bleeding ; to evacuate the
contents of the sac when suppuration has occurred, and to pre-
vent septic infection.

To secure the disappearance of a hematoma by absorption
cleanliness of the parts and rest are necessary. If the tumor
is vaginal or cervical, frequent irrigation of the vagina is ad-
visable. If the effusion is subcutaneous, cooling lotions and
inunctions with carbolized oil will often prevent inflammation and
rupture of the sac. If the tumor appears before or during labor,
and offers an obstacle to the delivery of the child, it must be
freely opened ; the contents, whether fluid or clotted blood,
evacuated ; pressure exerted by a tampon of iodoform gauze, in
order to check the hemorrhage ; while the extraction of the
infant by forceps or after-version is hastened as much as pos-
sible. To control the hemorrhage into the tissues before exter-
nal rupture has occurred, pressure, cold, and the internal admin-
istration of ergot may be tried. An ordinary tampon in the
vagina is not admissible, for it would dam back the lochial secre-
tion, and would become foul. Braun's colpeurynter, or a large
Barnes' bag, distended with ice- water, is the best appliance, for
it can be easily removed at frequent intervals to allow an anti-
septic irrigation of the vagina. If it is possible to avoid it, the
tumor should not he opened while it is increasing in size, for
there may be profuse hemorrhage at the time and a secondary
bleeding later. This does not occur, as a rule, when the tumor
is incised after the effusion ceases, and yet there are two cases

' Barker, loc. cit. 2 j ^^^ ^.// a if^c. at.

NON-INFECTIOUS FE VERS. 607

on record in which hemorrhage occurred from tumors opened
one and three weeks after their formation. ^ If the tumors are
too large to be absorbed, or if there is threatened gangrene of
their coverings, they should be opened.

Hematomata may burst within the first few days after their
formation, and there may be, in consequence of the rupture, an
alarming hemorrhage. In such cases it is best to enlarge the
opening ; to turn out the clots within the tumor ; to search for
the bleeding vessels, which may be seen spurting from the walls,
and to apply a ligature. If this is impossible, and bleeding still
continues, the cavity may be firmly packed with iodoform gauze,
firm external pressure being exerted by a large pad and a T-
bandage. The styptic salts of iron should not be applied, for
such a firm, dense clot is thus formed that it takes a long time
for it to disintegrate, the woman meanwhile running a risk of
septicemia.

After the coverings of a hematoma are incised or ruptured,
suppuration will commonly occur in the cavity ; septicemia must
be avoided in such cases either by an iodoform tampon in the
abscess-cavity often renewed, or else by frequently repeated
antiseptic injections. Suppuration may occur before the tumor
has been opened at all. In such cases the pus must be evacu-
ated. The opening should not be delayed too long, especially
in suppurating hematomata of the posterior vaginal wall, or
fistulae may result. The general treatment for loss of blood is
to be conducted in the ordinary manner when the indications call
for it — hypodermatics of ether, brandy, and other stimulants ;
hot animal broths internally ; "auto-infusion " by bandaging the
limbs ; and subcutaneous or intravenous infusions of a normal
salt solution.

Non-infectious Fevers. — Fever in the puerperal state not due
to infection may arise from emotion, from exposure to cold,
from constipation, from reflex irritation of any kind, from cerebral
disease, from eclampsia, from insolation, from syphilis, from the
exacerbation or persistence of an acute or chronic disease con-
tracted during or before pregnancy.

Emotional Fever. — In these cases there is simply a nervous
stimulation of or a disturbance of balance in the heat-controlling
centers of the brain, occasioned by some profound psychical
impression — as grief, anger, fear. The normal action of these
brain-centers may be disturbed by some powerful emotion which
profoundly affects the higher cerebral functions.

Another theory of fever after emotions deserves some con-

1 Parvin's ** Obstetrics," p. 502.

6o8

PATHOLOGY OF THE PUERPERIUM.

sideration. It is possible that the profound mental action pro-
duces a change in the composition of the blood or of the fluids
in glands and muscles, which, it is well known, take a part in
heat -production. It is possible that thus a thermogenic toxin is
manufactured.

There may, again, be an excitation or paralysis of the vasomotor
nerves. That fever may appear in consequence of emotions, clin-
ical evidence leaves no doubt. The cause of the fever being tran-
sient, perhaps momentary, the elevated temperature quickly sinks
to normal. Tt is not in every person that powerful emotionsare
followed by an elevation of temperature to a noteworthy degree.
There must, apparently, be predisposing causes in the nervous
system of the individual. Emotional fever is most often met with
in children, in hysterical girls,' and in women after child-birth.

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Fig. 45S.— Oiart of cm<.[ional fever from dread of an operalioi

In child-bed there is a curious irritability of the organism, a lack
of control over the mental processes. The petulant child, easily
swayed by and completely yielding to emotions, subject on slight
provocation to cemvulsions. is a familiar picture; and no one can
overlook thi.s .same mental and ner\'Ous character in pregnancy
and in the early part of the puerperal state. It is this condition
of the nervous system, apparently, that predi.sposcs to emotional
fever. It is, therefore, not at all uncommon in the puerperium.

Hunt's^ recortJK of seventy-five cases, confined to w^omen free
from infection and inflammation, in which the temperature was

1881, vol. ii.

ex,-,n,ple;
1'. 790)-

he tcni;icralure

l>ernlure,""

Praclilione

," Ijmdon. 188.

NON-INFECTIOUS FEVERS. 609

taken twice a day in the month, gives three apparently typical ex-
amples of fever from emotion. I have seen a number of examples
of emotional fevers. Failure to receive an expected letter, fear of
exposure in illegitimate pregnancy, the expected removal of
the woman's infant to an asylum, dread of an operation, and a
variety of mental disturbances have given rise in my experience
to a high but transitory fever. Figure 458 shows the tempera-
ture record of a typical case. There had been one operation for
suppuration in the breast in a hospital ward. It was witnessed
by two puerperal patients. One of these, a young girl, shortly
after experienced pain in the breast. She at once conceived a
morbid dread of an operation in her own case. The beginning
elevation of temperature in the chart indicates the commence-

Djyol

^/|

1(6=
10*=
103^
103=
101'^
1CX)=

'■

{

08=-

fig- 4S9- — Chart of fever case from exposure lo cold. The patient left her bed
ice against orders, in ber bare feel and night-gown. Each time there was a rise
lempermturc, quickly subsiding.

ment of engorgement and pain in the breast. These symptoms
continued for a few days, when, after lying awake all night
brooding on the subject, the girl's temperature began to rise in
the morning, finally reaching the height indicated on the chart.
The only antipyretic employed was the emphatic assurance of the
resident physician that there was not, and would not be, the
slightest excuse for an incision in the breast. The patient's fears
being allayed, her temperature quickly sank to normal, where it
remained.

Pever from Exposure to Cold. — In the sensitive condition of
puerperae it is not uncommon to see a febrile reaction follow
undue exposure. A careless nurse or attendant may be respon-
39

6io

PATHOLOGY OF THE PUERPERIUM.

sible for too low a temperature in the lying-in room, or for ill-
regulated ventilation, or for insufficient or ill-arranged bed-
clothing. A wilful patient may leave her bed too soon and
expose herself, thinly clad, to cold (Fig. 459).

Peverfrom Constipation. — Schroeder^ says that " among the
causes, aside from infection and local inflammations, which, with
special frequency, produce fever in the puerperal state, overdis-
tention of the intestines with fecal masses should be given a fore-
most place." This statement is, I think, exaggerated. Every
practitioner of obstetrics, however, sees examples of this sort of
"puerperal fever" (Fig. 460).

D..OI

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IM"
103°
103°
101'
100°
90°
98=

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iif£

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Fig. 460.— Chart of a wc
puerperal alate. There had In
and then none for six daya. .
temperature lo nonnal in a few

con<itipated for six days in the latter part of the
le movemcnl of Ihe bowels, five days after labor,
;e dose of castor oil and an enema reduced (he

The temperature-chart, figure 460, is that of a woman in
the Philadelphia Hospital who had had but one evacuation of
the bowels — on the fifth day — in the eleven days succeeding
delivery. The temperature rose to a great height, but fell im-
mediately after a large dose of castor oil and the administration
of an enema, which produced an enormous fecal evacuation.

Fever from Reflex Irritation. — Physical irritation, as well as
psychical, maj' be reflected in general elevation of the body-
tcniperature during the puerperal state. The irritating point is
most often in the breast. There may frequently be found, in
women of sensitive nervous organism, a well-marked fever, which

■ " Lehrbuch," 8. Aufl., S. 8oj.

NON- INFECTIOUS FEVERS.

6ii

can be traced to no other cause than engorgtment and distention
of the mammary gland. There is usually a history of exposure
to cold or drafts of air in nursing the child. For twenty-four
hours afterward there will be high fever and every evidence of

/ £ 3 «■ 5 6 y & 9 10 n 12 }3 />* IS

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acute illness. Heat to the breast, evacuation, and support of
the gland and a saline purge dissipate the symptoms in twenty-
four hours. The appended temperature-chart (Fig. 461) illus-
trates the influence of mammary congestion upon the temperature.
A young primipara developed, on the eighth day of the puerperal

is^

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Fig. 461. — Fever Toltowed by expulsion of lape-w

•Tenia passed from bowel.

State, apparently an acute mastitis. The pain, the redness of the
skin, the swelling of the breasts, and the course of the tempera-
ture indicated that suppuration had occurred. Consequently, a
deep incision was made into the gland ; there was free bleeding, but

6l2

PATHOLOGY OF THE PUERPERIUM.

not a drop of pus was found. Immediately after the incision,
which reheved the engorgement of the breast and the tension of
the skin, the temperature fell to normal.

The focus of irritation may be anywhere in the body. A
primipara was delivered under my care without difficulty of a
healthy infant. During the early part of the puerperal state she
complained of a constant and distressing headache ; diarrhea
appeared, which resisted treatment, and the woman's mental state
tended rapidly toward pronounced melancholia. There was
fever, apparently of a septic character. On the ninth day the
body of a tape-worm fourteen and one-half feet long was passed
from the bowel, and shortly after-
ward the temperature became nor-
mal.

The great elevation of tempera-
ture which often follows perforation
of the uterus into the peritoneal
cavity, appearing, as it commonly
does, immediately, should also be
attributed more to an intense reflex
irritation than to septicemia. The
chart, figure 463, is from a case in
which the placenta was abnormally
adherent. Separation was accom-
plished four hours after delivery by
means of the fingers and a curet
Fie. 46J.— Riseof (empem- Ulceration of a limited area in the
lure following perforation of the placental site followed, which ended
""™'' in perforation and death on the third

day. High fever occasionally appears
in consequence of an acute retrodispiacement of the puerperal
uterus, sometimes as late as the fourth week. If the rise of
temperature is simply due to irritation, it subsides within a few
hour.s after the uterus is replaced.

Fever in the Puerperal State from Cerebral Disease. —
A puerpera might have a tumor in the brain or spinal cord, in-
sular sclerosis, locomotor ataxia, or degenerative changes in the
brain — all of which could give rise to elevations of temperature.*
It is, however, to cerebral hemorrhages and embolism that one
should usually look for an explanation of fever arising from brain
disease, for these accidents are by no means rare in the puerperal
state ; and if the hemorrhage or embolism affects certain regions,
a rise of temperature, often to a great height, is almost sure to
il-centcr, from a Clinical Poinl of

<vr

107"
108°
105=
104°
103°
103=
101"

NON-INFECTIOUS FEVERS.

613

follow. A temperature of 108° in the axilla has been noted in a
case of cerebral embolism following child-birth,'

Fever with Eclampsia. — It is justifiable to put the fever of
eclampsia among the non-infectious fevers of the puerperal state.
Winckel,' writing in 1878, said he had observed and had
called attention to the fever accompanying eclampsia fifteen
years before ; he was accordingly the first to refer to it Boume-
ville and Budin published this fact as an original discovery in
1872,

With each convulsion there is a notable rise of temperature,
until, finally, the fever may run very high.

D>»u'.

108°
106=
104°
10»=
103°
101=
100°
99°

■

Fig, 464, — Fever-chart of palieni i

d of eclampsia.

Insolation. — Sun-stroke, or heat-stroke, is by no means an
impossible accident to lying-in women in the torrid tempera-
ture of the American summer. The only case, however, that
I know of occurred at sea in, a ship sailing from France to
New Orleans,^ The cabin in which the woman was confined
was hot and ill-ventilated. The temperature of the air was
93,4° F. A portion of the membranes was left behind, and
the discharge was offensive, but there was no fever. On the
fourth day, however, the temperature rose to 104°, and shortly

' Ne«, " A Caw of Cerebral Emboli
birth." "Lancet," 1884, ii, p, 103,

" " Path, u, Theiap, des Woch en belles," 3, Aufl,, 1878. S, 493.

* Skinner, " Sur un Cas d'Hyperthennie poil-puerptrale," '
midicale," 1887, p, 269.

with Hyperpyrexia fotlowing Child-
Ftogtti

6i4

PATHOLOGY OF THE FUERPERIUM.

after mounted to 109.4° in the rectum. The woman ultimately
recovered.

Syphilitic Fever. — Mewis.i from an analysis of 167 cases
of syphilis in lying-in women, came to the conclusion that the
influence of the puerperal state upon the local lesions of the
disease was a favorable one, but he called attention to a spe-
cial tendency in Syphilitic women to specific febrile action and to
peri-uterine inflammations during the pucrperium. Fournier's
discovery of a specific syphilitic fever naturally turned the
attention of French writers and students to this matter, and

Fig. 465. — Tempei

there were four elaborate theses on the subject written in the
years 1885-86 in Paris. ^

It appears from these studies that the proportion of sj-ph-
ilitic fever to be looked for in women after child-birth is only a
trifle over two per cent, of women affected with the disease.
In my experience with syphilitic women in child-bed, the
disea.sc has complicated puerperal convalescence by the re-
tention within the uterus of the hypcrtrophied deciduous
membrane,^ which is so often seen as a result of syphilis, by

Syphilitiques," Paris, 1886.
lelritis in Pregnane}' and the Puerperal

NON-INFECTIOUS FEVERS. 615

adherent placenta, by the development of pelvic exudates, and,
as in one instance, by septic infection, which occurred in con-
sequence of large ulcerated surfaces in the vagina that had
developed during pregnancy.

Persistence or Exacerbation of Febrile Affections in tiie
Puerperal State. — A woman may acquire any of the acute
or chronic fevers during pregnancy, which may persist in the
puerperal state or take on new activity during that period.
This is true of all the infectious diseases, but particularly so
of phthisis. The effect of labor upon the course of phthisis
has interested many observers. It has been asserted that the
disease makes no progress, or, at least, is very much retarded
in the puerperal state. There is a fictitious appearance of
regained health in the woman by reason of the accumulation
of fat to which pregnancy disposes. The laity, therefore, enter-

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■X pregnancy and the

tain the idea that it is an advantage for the phthisical i
to become pregnant. No mistake could be more unfortunate.
The drain and strain of the child-bearing processes are often
accountable for the origin of phthisis in a woman disposed
to tuberculosis, and, if the disease already exists, there is after
delivery an exacerbation of the fever, an aggravation of the
pulmonary symptom, and a rapid loss of strength and vitahty,
which shortens the patient's life by many months. It is the
duty of a physician to advise the tuberculous subject against
marriage or maternity.

Acute Intercurrent Affections In the Puerperal State. —
Any one of the acute diseases may fasten itself upon a woman after
confinement. They acquire a special interest in this condition, for
their course is often modified, the prognosis is commonly graver,
and the diagnosis is more difficult. It is often difficult and
occasionally impossible to distinguish certain diseases — as erysip-

6 1 6 PA THOLOG Y OF THE PUERPERIUM.

elas, diphtheria, malaria, scariet fever, and typhoid fever, occurring
during the lying-in period — ^from septic infection.

Pneumonia. — Pneumonia does not attack women so often as
it does men, but it is more fatal in the former. Pregnancy and
the puerperal state are grave complications of the disease. They
increase the gravity of the symptoms and make the prognosis
unfavorable. Pneumonia more frequently attacks a woman dur-
ing the nine months of pregnancy than during the six weeks of
the puerperal state, but the pneumonia of pregnancy often be-
comes a complication of the pucrperium, for frequently the
disease induces a premature expulsion of the ovum at the height
of the attack, and convalescence or death occurs in the lying-in
period. In 43 cases of pneumonia in pregnancy collected by
Ricau,^ there was premature expulsion of the fetus in 21.
From these statistics it further appears that the likelihood of
the accident is increased after the sixth month. In 28 of the
43 observations the women had not passed the sixth month of
pregnancy ; of this number 1 1 aborted. Of the other cases,
however, 15 in number, in which the pregnancy was past six
months, there was premature labor in 10 instances.

The prognosis of pneumonia in pregnant women is grave.
Of Ricau's 43 cases, 12 died: 5 before the sixth month; 7
after it. The infants were expelled in 21 cases prematurely;
and of those which had reached sufficient development to exist
outside the uterus the majority died. Tarnier ^ sums up the
outlook for mother and child in the following way : The more
advanced the pregnancy,the greater the probability of an expul-
sion of the fetus, the graver the prognosis for mother and child.

Treatment. — A discussion of the medical treatment of pneu-
monia has no place here. A consideration of the obstetrical
treatment of the disease when it attacks the pregnant woman
is important and is best handled by the obstetrician. The ques-
tion to be decided by him is whether he will induce labor
or avoid interference. Pregnancy complicates pneumonia by
mechanically increasing the difficulty of respiration, by calling
upon the heart for extra work, and by demanding unusual
facilities for disposing of the waste-products of two organisms,
part of which should be dischaiged through the lungs. It
would seem, therefore, that the uterine cavity should be emptied
for the mother's sake, more especially as the infant deserves
but small consideration, being almost certainly doomed. But

i"Thdsede Paris," 1S74.

2 Tarnier et Hudin, " Trait6 de TArt des Accouchements," t. ii, Paris, 1886.

INTERCURRENT DISEASES. 6 1 7

the evacuation of the uterus, the contraction of its walls, and
great diminution of its blood-supply favor a determination of
blood to other internal organs, among them the lungs. The
exhausting discharges of the puerperal state, moreover, may
fatally waste the patient's strength, while in her feeble and
unresisting condition it is possible at least to have a general
septic infection added to the pulmonary disease. Statistics cer-
tainly do not speak in favor of artificially inducing abortion or
premature labor. Matton ^ says that of 1 8 cases in which preg-
nancy was interrupted 9 women died, while in 20 women who
suffered from pneumonia without abortion but i succumbed.
Tamier justly remarks that in the former series the disease was
probably more malignant, and that this fact accounted for the
abortions as well as for the fatal issue in so large a proportion ;
and of the 20 cases it was, perhaps, on account of a mild attack
of the disease that none aborted and but i died. There are,
however, 2 recorded cases in which death occurred without the
previous interruption of pregnancy. Chatelain's ^ statistics in-
clude 39 cases ; in 10, abortion occurred ; in 9, premature labor
was induced. Of the 19, 10 died, and of the remaining 20, 10
also died, showing that little was gained by the interruption of
pregnancy. It must be remembered, too. that it requires con-
siderable time and also a certain amount of operative interference
to induce abortion or premature labor, and during the process
the woman may die. On the other hand, it is an undoubted fact
that, temporarily at least, the symptoms are often somewhat
relieved after the expulsion of the uterine contents.

My experience embraces 5 cases of pneumonia in pregnancy
and 3 in the puerperium. Of the 5 women attacked during
pregnancy, all expelled their infants prematurely, 3 died, and
2 recovered. One of the latter had double pneumonia. Of
the 3 women who acquired the disease after labor, i died and 2
recovered. Of the 5 infants bom in the midst of the disease,
4 died.

Pleurisy may possibly complicate the puerperal state. It
would be simply an intercurrent affection, to be treated on gen-
eral principles. It does not influence the course of pregnancy,
nor is it influenced by the woman's condition.

The Exanthemata. — Scarlet Fever. — Although this disease
in the puerperal state has attracted much attention and aroused
extended discussion among medical writers, there are still several
points in its relationship with the puerperium in dispute. It is

1 '* Jour, de Med. de Bruxelles," 1872, p. 412.

2 Ibid.^ 1870, t. 1, pp. 430, 516, and t. li, p. II.

6 1 8 PA TIIOL OGY OF THE PUERPERIUM,

not Strange that there should be some confusion and difference
of opinion in regard to scarlet fever in the puerpera, for its course
is often much modified by the woman's condition ; it may be
complicated by the coexistence of septic infection ; there may be,
on the other hand, scarlatiniform rashes in the course of septi-
cemia, although scarlatina is excluded ; and, moreover, there
may be, in certain cases, after infection with the poison of scar-
latina, a train of pelvic symptoms indistinguishable from that
which commonly follows the entrance into the body of septic
micro-organisms.

Frequency. — Scarlet fever is a rare complication of the puerperal
state. Prior to 1876 Olshausen ^ collected 134 cases ; Winckel ^
saw one in Rostock ; single cases are likewise reported by Pal-
mer,^ Parvin,^ Busby, ^ Harvey,^ Cummins,"^ and the author.
Braxton-Hicks * asserts that he has met with 37 cases (!), chiefly
in consulting practice. Epidemics of scarlet fever among puer-
perae are described by Boxall ^ and Meyer, ^® in which, respec-
tively, 16 and 18 women were attacked by the disease. In the
discussion on Boxall' s paper, several members of the London
Obstetrical Society ^elated individual experiences with the dis-
ease. It can not be asserted that puerperae are peculiarly dis-
posed to scarlet fever, tlpidemics occur, it is true, in lying-in
hospitals at long intervals, but the proportion of patients at-
tacked is never very large. During the epidemic in the Ma-
ternity Hospital of Copenhagen, described by Meyer, only about
one per cent, of the lying-in patients acquired the disease. Box-
all says that 40 women were exposed to the contagion of scarlet
fever during an epidemic, without the slightest detriment to their
health. During the years i87i-'85 there were only 2 cases of
scarlet fever, in the lying-in period, among the patients at the
Copenhagen Maternity ; in six years but 3 cases of the kind were
seen in the hospital for infectious diseases (Meyer). In a ten
years' hospital service in the Philadelphia, Maternity, and Uni-
versity Hospitals, I have seen but 2 cases of true scarlet fever in
the pueq^crium.

Ififection and Incubation. — Women after child-birth may be

J •' Archiv f. Gyn.," Bd. ix, S. 169.

2 ♦* Path. u. Therap. des Wochenbettes," 1878, p. 529.

3 "Cincinnati Lancet-Clinic," 1887, ix, 481.

4 " Amer. Jour. Med. Sci.," 1884, 179. » Ibiii., 1887, p. 394.

« •' Scarlet Fever and the Puerperal State," •* X. V. Med. Record," 1886, xxx,
376. ' " British Med. Jour.," 1884, i, 760.

^ "London Ohst. Trans.," vol. xii, pp. 44-II3.

^ Abstract from " London Ohst. Trans." in "Anier. Jour, of Obstetrics," 1888,
PP- 547. 553. (^^'^^■

^^ *' Ueber Scharlach bei Woclnicrinnen," *' Zeit. f. Geburtsh.," Bd. xiv, S. 289.

INTERCURRENT DISEASES. 6 1 9

infected with the poison of scarlet fever in the ordinary manner —
through the throat — or through wounds in the genitaUa. The
latter statement has been disputed, but the short period of incu-
bation, the fact that the rash often begins at the vulva and spreads
thence over the trunk, the common occurrence of pelvic inflam-
mations, and the fact that the diphtheric patches usually seen
in the throat of scarlet-fever patients are met with commonly in
the vagina when the disease attacks a lying-in woman, while the
throat is affected to a minor degree or entirely spared — all indi-
cate the genitalia as the point of entrance for the specific materics
morbi. It is likely that the majority of women affected during
the puerperium are infected by actual contact with the disease
germs on fingers or instruments inserted in the vagina ; but it is
quite possible that the poison of the disease may be drawn into
the throat from the atmosphere or may be conveyed to the geni-
talia by the same medium. Before the adoption of antiseptic
measures in surgical practice it was well understood that the poi-
son of scarlet fever might find entrance to the body through a
solution of continuity in the skin and mucous membranes. Paget
long ago pointed out that the wounded are more susceptible
to scarlatina. ^ The woman after child-birth is always a wounded
person, and she is also more susceptible to attacks of the
disease. This puerperal susceptibility explains the cases which,
exposed to the contagion during pregnancy, only manifest the
symptoms of the disease after labor, the poison having lain dor-
mant for varying lengths of time until its invasion of the body is
facilitated by the wounds and abrasions which always attend
parturition (Olshausen). This mode of entrance would also
explain the short period of incubation when scarlet fever attacks
a puerpera. Ordinarily, five to seven days intervene between
the date of infection and the appearance of the first general
symptoms. In the puerperal state, however, the time of incu-
bation is shortened to twenty-four or forty-eight hours (Senn,
Hervieux, Olshausen). In one of my cases the patient, two
weeks before her confinement, had handled some old linen that
had been used in a fatal case of scarlatina ten years before. She
developed a violent and typical attack of scarlet fever forty-eight
hours after her delivery.

Olshausen ^ says that four-fifths of all puerperae attacked will
manifest the first symptoms at some time in the first three days
after labor ; and this assertion has been supported by the major-
ity of the cases reported since the appearance of his article.

Symptoms and Diagnosis. — A frank case of scarlet fever in

* See also Hoffa, Volkmann's **Samml. klin. Vortrige,*' No. 292.

* Loc. cit.

620 PATHOLOGY OF THE PUERPERIUM,

the puerperal state is as easily recognizable as it is under
any other circumstances in the adult male or female. But
" in rare instances the disease may assume a masked form
in which the ordinary signs of scarlatina are absent, or so slight
and evanescent as to escape observation," and " in some such
cases the only manifestation of the illness may be found in
signs usually referred to septic poisoning " (Boxall). ^ It is, more-
over, a well-recognized fact that one of the manifestations or
accompaniments of septicemia in occasional cases is the appear-
ance of a scarlatiniform rash. And, again, there are reported,
from time to time, erythematous eruptions in the puerperal state
resembling, on the one hand, the rash of scarlet fever, and. on the
other, the eruption sometimes associated with general sepsis, ^ and
yet apparently unconnected with either of these diseases. Finally,
there may coexist in the same individual local inflammations about
the pelvic organs of septic origin and a general infection of the
whole organism with the poison of scarlet fever. It '\s> obvious,
therefore, that a definite diagnosis of scarlet fever in the puerperal
state may be difficult or even impossible. The diffuse nature of
the rash, followed by desquamation ; the characteristic appear-
ance of the tongue ; the affection of the throat ; the more exag-
gerated diphtheroid inflammation of the vagina ; the exposure
to the contagion of the disease ; the occurrence of scarlatinous
nephritis ; finally, the infection of those who come in contact
with the patient and the subsequent outbreak in them of a typi-
cal case of the disease,^ make the diagnosis certain. But there
are cases in which the existence of the disease, with symptoms
closely resembling sepsis, is overlooked, or, if suspected, is only
inferred.

The Peculiarities of Scai'lct Fci'er in the Puerperal State. —
Olshausen asserts that scarlet fever is modified in three ways when
the disease appears during the puerperium ; it almost always
appears in the first three days after labor ; the throat complica-
tions are slight ; the eruption appears quickly, is rapidly diffused
over the body, and is apt to assume a dark-red color. Winckel
states that convalescence is commonly tedious. A careful study
of the published cases must convince any one that scarlet fever

^ Braxton- Hicks takes an extreme position in this connection. He says that
amonjT sixty-eight cases of puerperal diseases in his practice for which there was a
demonstrable cause, thirty-seven were due to scarlet fever. This is, no doubt, an
overestimate, and it has not met with general acceptance. Even Boxall's moderate
statement, however, has a long list of names arrayed in op}X)silion to it, but, to the
writer s mind, the weight of evidence is distinctly in favor of his view.

2 This word is used, in default of a better, to designate infection by the com-
moner pyogenic micro-organisms.

^ See the cases rei)orted by Palmer and Harvey, loc. cit.

INTERCURRENT DISEASES, 62 1

exercises an unfavorable influence upon the puerperal state.
The milk -secretion is often lessened, if not suppressed ; there
is often some change in the lochia, denoting probably an
exanthematous endometritis or a diphtheric inflammation of
the vagina. In a number of the cases reported, fetid lochia is
noted; in some a ** peculiar odor" is described; the only
change noticed may be an increase or a return of the lochia
rubra. In a considerable proportion of all the cases the
discharges from the genitalia are unaffected. In 10 of the
cases reported by Meyer rheumatic complications were ob-
served. In 2 1 of the cases collected by Olshausen there was
an evanescent tenderness over the uterus. The occurrence of
pelvic inflammation is reported in so large a proportion of the
entire number of cases that the association can not be a mere
coincidence. Of Meyer's cases, for instance, 6 presented evidence
of peri- and parametritis. It is possible that the specific poison
of scarlet fever is capable of causing a pelvic peritonitis or an
inflammation of the pelvic connective tissue when it enters the
body through the wounds along the genital tract or finds en-
trance to the peritoneal cavity through the tubes. Or, per-
haps, there may be a ** mixed infection," as happens in gonor-
rhea. Whatever the explanation, it is highly probable that
pelvic inflammation may occur as a consequence of scarlatinous
infection during or after labor. Diarrhea may develop early in
the attack. It is an unfavorable sign. Of 21 women in
Olshausen's series thus affected, i 5 died.

Prognosis. — If the attack is a frank one ; if the genitalia are
not much involved ; if the pelvic tissues are not extensively in-
flamed, the woman will probably recover. It would scarcely be
correct, however, to assert that the prognosis of scarlet fever in
the puerperal state is favorable. The* death-rate among Ols-
hausen's cases w^as 48 per cent. ; of those infected immediately
after labor, 75 percent. Of Meyer's 18 cases, i died. The 3
cases observed by Martin all died. Of Braxton-Hicks' 37
patients, 27 died. Many of these, how^ever, were not cases of
scarlet fever, but were probably cases of puerperal infection with
a septic erythema. Galabin ^ twice saw fatal peritonitis during
desquamation. On the other hand, Hervieux had 7 cases which
ended favorably. All of Boxall's cases recovered. Legendre ^
reports 23 cases without a death. The single examples reported
by Palmer, Parvan, Busey, Harvey, and Cummins all ended in
recovery. The two patients under my observation recovered.

* Discussion on Boxall's paper, he. cit. ^ See Parvin, /oc. cit.

622 PATHOLOGY OF THE PUERPERIUM.

In scarlet fever, as in all the contagious diseases of the puer-
perium, the patient must be isolated and should not be allowed
to nurse her child.

Erythematous Rashes in the Puerperal State. — A rash some-
what resembling the exanthem of scarlet fever sometimes makes
its appearance on the skin of a puerpera, but a distinction
can usually be made between the two. In the simple erythema
there is apt to be a moderate and evanescent fever, ^ the pulse is
rapid, and in most cases fetid lochia is noted, ^ with some uterine
or pelvic tenderness ; there is often intense itching and usually
desquamation ; miliaria often make their appearance, especially
on the abdomen under the binder, and there may be desqua-
mation. The eruption is very likely the expression of a sep-
tic infection, usually of a mild degree ; but occasionally ery-
thema may be associated with the gravest forms of septicemia.
Mackness explains the eruption by the supposition that some
septic products are evacuated through the sweat-glands, irritat-
ing the skin and producing a general hyperemia. His theory is
supported by the fact that the rash is at first punctate, seeming
to begin usually at the hair-bulbs, and soon after becoming
difiTuse. The belief in the septic nature of the eruption is shared
by Winckel, Kaposi, Maygrier, Geneix, Farre, and many others.
The superficial resemblance that this affection bears to scarlet
fever has led many observers into error. Raymond ^ would
have one believ^e that the eruption is the manifestation of an
attenuated form of scarlet fever. With the same idea in mind
Gueniot calls the rash scarlatinoid. It is likely that future
investigation will confirm an opinion, already expressed, that
there is an " infectious erythema " dependent upon the invasion
of the body by a specific microbe, which, it is claimed, has been
already isolated."^ »

Loviot ^ has reported an er>^thema recurring a number of
times during a year after an attack of puer{>eral sepsis. Lipin-
sky ^ also reports two cases of recurrent erythema in the puer-
perium. Gacrtig '^ reports an erythema recurring after three
successive labors, twice with fever, the third time without

* Mackness, " Some Scarlatinous Rashes Occurring During the Puerperium,"
" Edinb. Med. Jour.," August, 1888.

2 Mackness, loc. cit. ; Mac Donald, ** Edinb. Obst. Soc. Trans.,'* 1884-^85, x,
235; Charpentier ; (iu^niot, "Th^se," 1862 ; Pouj>on, " Eryth^me scarlatiniform
chez une Ferame rccemment accouchee," " I^ Erance m^dicale," 1884, i, 41.

'^ " Tht^se d' Aggregation."

* Simon et Eegrain, ''Contribution ^ I'ttude de I'ferythdme infectieux,"
" Ann. de Dermatol, et de Syphilog.,'' November, 1888.

* ** Annales de Gyn.," July, 1894. « " Centralbl. f. Gyn." 1894.
' 3i(/.f p. 720.

INTERCURRENT DISEASES. 62 3

Measles. — Pregnant women are rarely attacked by measles.
The disease is even more rare in the puerperal state, owing to
the shorter duration of the period. The measles of pregnancy,
however, usually becomes a complication of the puerperium by
inducing an expulsion of the ovum. Nine out of eleven cases
of measles during pregnancy reported by Klotz ^ caused a pre-
mature expulsion of the fetus. Occasionally, the disease first
manifests itself in the puerperal state. Tarnier ^ describes an
instance in his own experience. Measles in the child-bearing
woman is a dangerous disease. There is a disposition to
heniorrhage, and pneumonia is a frequent and a very dangerous
complication. ^

Small-pox. — Pregnancy and the puerperium increase the
gravity of all the eruptive fevers. This is true of small -pox
as of the rest. Luckily, the disease is a rare one under any
circumstances in this country, and as a complication of the
puerperal state it is of very exceptional occurrence.

A case of r'dtheln * during the puerperal state has been re-
ported. I have also observed one case, mild in character, end-
ing in recovery.

Erysipelas. — The practical identity of the streptococcus ery-
sipelatis and the streptococcus pyogenes explains the fact that
the germs of the disease, when introduced into wounds along the
genital canal or into the uterus, are capable of generating a violent
form of puerperal sepsis without manifesting externally the rash,
which is supposed to be distinctive of erysipelas. Goodell ^ said :
" That there is a relation between the diseases of erysipelas and
puerperal infection, I am satisfied." Dr. Goodell, in the course of
his remarks, quoted the case of a physician who, while in attend-
ance upon an erysipelatous patient, delivered seven women.
Five of them died of puerperal fever without showing external
evidence of the disease in a rash. Dr. Fordyce Barker,^ on the
same occasion, said : ** The intimate relation between puerperal
fever and erysipelas I consider as firmly established as is any fact
in medicine." He referred to the epidemic of black tongue in
Connecticut, which he witnessed in the early part of his profes-
sional career, and stated that every woman who was confined at

1 "Archiv f. Gyn.," Bd. xxix, S. 448.

' Tarnier et Budin, *• Path, de la Grossesse,'* p. 17. A good bibliography pre-
cedes the chapter.

3 Two fatal cases are reported by Hul hurt, ** St Louis Courier of Medicine,"
1887, xvii, p. 549.

* Kite, •* Boston Med. and Surg. Jour.," August 18, 1887.

* Discussion on Dr. Campbell's paper, ** Erysipelas in Child-bed without Puer-
peral Peritonitis," "Trans. Amer. Gynec. Soc.," vol. vi, 1881.

* Ibid.

624 ^^ THOLOG V OF THE PUERPERIUM.

that time in the region devastated by the epidemic had puerperal
fever, and he thought every one of these women died. Dr.
Barker also spoke of a physician who contracted a fatal case of
erysipelas from a patient whom he attended in puerperal fever.
Statistics gathered in Belgium show plainly the connection
between outbreaks of puerperal fever and of erysipelas in certain
districts.^ In an analysis of the Belgium health reports it was
found that the number of localities where erysipelas and puer-
peral affections were noted at the same time numbered 456,
while there were only 1 54 districts in which puerperal afiections
were observed alone without accompanying outbreaks of erysip-
elas. In discussing Dr. Boxall's paper on ** Scarlet Fever in
the Puerperal State," ^ Dr Playfair said, ** Twenty-five years
ago a lying-in ward was established in King's College Hospital.
The arrangement was disastrous, and was at length abandoned.
During the existence of the ward there were outbreaks of ery-
sipelas in the surgical quarter of the hospital and coincident
epidemics of puerperal fever in that ward, but the lying-in
patients had no symptoms of erysipelas ; which, on the other
hand, was seen in some of their infants." A large number of
cases might be cited in which contact with puerperal-fever
patients originated an attack of erysipelas, or, on the other hand,
in which puerperal exposed to the contagion of erysipelas devel-
oped virulent forms of puerperal sepsis.^

0 Pneumonia is a frequent complication of puerperal erysipelas.
During an epidemic that Winckel observed in 1880, six out of
thirteen puerpcraL* attacked manifested this complication.

In relation to erysipelas, as to all the infectious fevers of the
puerperium, it is important for the obstetrician to realize that if
these diseases fasten themselves upon the woman after child-birth
in the ordinary manner, — that is, erysipelas through a scratch in
the skin, scarlet fever from the throat or lungs, and so on, — ^their
course, symptoms, and treatment differ very little from the or-
dinary manifestations and management of the respective diseases
in an adult female ; but when any of these poisons enter the
woman's system through wounds along the genital canal, the
history is a very different one. The train of symptoms produced
is, to a great extent, the same, no matter what the nature of
the poison wliich has found entrance to the body. There
mav be the same endometritis, the same involvement of the
uterine wails, of the lymphatics, of the blood-vessels, of the

^ '* L'Ervsipdle et les Femmes en Couches," Jorisenne, "Archives dc Tocol.,"
XV, 1888, p. 302. 2 "Trans. London Obst. Soc," 1888.

^ Winckel. " Ueher das pucrperale Krysipel," Separat Abdruck aus dem "Acrzt-
lichen Intelligenz-lilatt,'' Miinchen, 1885.

INTERCURRENT DISEASES. 62 5

connective tissue, and of the serous membranes after infection
of the pelvic organs by any one of the numerous pathogenic
micro-organisms. Winckel has seen, in all, 42 cases of ery-
sipelas during pregnancy and the puerperal state ; 36 of them
developed after the delivery of the infant ; 6 occurred during
pregnancy. Of the cases in pregnant women, not one had its
origin in the genitalia. Of the 36 cases in the puerperal state,
28 began in the genitalia, 2 in the breast, and the remainder in
the face and scalp. Winckel, from an extensive study of the
subject, offers the following points of evidence as to the etiology
of erysipelas in the puerperal state and its connection with
puerperal sepsis :

1. By far the most frequent points of origin — in five-sevenths
of all the cases — ^for puerperal erysipelas are the genitalia and
nates. There are endemics in which not a single case of facial
erysipelas appears.

2. Primiparae contract the disease three to four times as fre-
quently as multiparas.

3. Puerperal with wounds upon the genitalia are particularly
predisposed to the disease.

4. Those who have undergone difficult operative deliveries
acquire the disease much more frequently than others.

5. The children of lying-in women with erysipelas remain, in
my ( Winckel' s) experience, free from the disease. (Gusserow, in
fourteen cases, saw the child infected twice ; in Goodell's expe-
rience this happened once.)

6. The larger the number of women diseased in a puerperal -
fever epidemic, the larger is also the number of erysipelatous cases.

Frequency. — Erysipelas in the puerperal state manifested by
a cutaneous eruption is very uncommon.

Symptoms and Diagnosis. — If the erj'sipelas manifests its ex-
istence by a cutaneous eruption, the symptoms are distinctive and
the diagnosis is plain. If, on the contrary, the streptococci in-
vade internal organs and tissues, it is impossible to differentiate
the case from one of ordinary streptococcus infection.

Prognosis. — If the case is one of frank erysipelas, starting
from the breast or the face, the prognosis is relatively favorable.
Among 14 cases of the kind described by Winckel there were
only 2 deaths. Of the 28 cases in which the erysipelas orig-
inated about the vulva 12 ended fatally.^

^ It goes without saying that the puerperal state predisposes to attacks of ery-
sipelas by furnishing so many points of entrance for the poison in the wounds of
various degrees along the genital canal. It would seem, also, that the condition of
the whole organism favored the occurrence of the disease. I)6derlein (** Milnch.
med. Wochens. ," xxv. 1888) reports a case in which the poison lay latent for a
year in a lymphatic gland and broke out into fresh activity after an abortion.
40

626 PA THOL OG Y OF THE PUERPERIUM.

Treatment, — The treatment of erysipelas of regions distant
from the pelvic organs in the puerpera differs in no respect from
the treatment of the disease under any circumstances, except that
the greatest care must be exercised not to transfer the strepto-
coccus infection to the genitalia, and not to allow the child to
nurse from an infected breast.

Puerperal Diphtheria. — If infection occurs in the throat, the
disease is an accidental complication of the puerperal state. If
the infection has occurred in the genitalia, a variety of puerperal
sepsis ensues that is considered in another place.

Puerperal Malaria. — Malaria is something more than an
acute intercurrent affection of the puerperal state, for in some
important particulars the condition of the woman's organism after
labor modifies the disease. The liability to infection is increased
after child-birth. This is a proposition which is now beyond dis-
pute. It has long been recognized and will be verified by the
experience of every observant physician. Bonfils,^ in a thesis,
has collected 140 observations of malarial fever in child-bearing
women and has carefully studied the articles on this subject
written by Pitre, Aubinais, Duboue, Ritter, Dupuy, Bureau, Goth,
Pasquali, Bompiani, Cuzzi, and Mangiagalli. As the result of
his investigation Bonfils came to the following conclusions in
regard to the influence of malaria upon the puerperal state and
to the modifications exhibited by the disease in this condition :
Malarial fever after child-birth predisposes to puerperal hemor-
rhages, which occur apparently in consequence of the dis-
turbances in blood-pressure accompanying the chills and
fever. The lacteal secretion is suppressed during the exacer-
bation of fever, but appears again after the febrile stage ; it is,
however, less abundant. Whether or not the milk can convey
the specific poison of malaria from the mother to the nursing
infant is an undecided question. The most striking phenom-
enon in the puerperal state of women already infected with
malaria is the reawakening of malarial manifestations, probably
by reason of the traumatism and the physical depression follow-
ing child-birth. The third day after labor seems to be the usual
time for the reappearance of the disease, probably because of the
slight elevation of temj)erature and of the general excitement of
the organism which accompanies the establishment of lacUition.
The fever preserves, during the puerperal state, a jxirfect periodic-
ity, a characteristic which much facilitates the diagnosis. Spieg-
elberg and Ritter, however, stand opposed to this doctrine. In
their opinion regularity in the occurrence of fever is very rare

^ *' Pahulisme ct Tuerpcralitc," " Ann. de Gyn6c.," 1886, xxvi, 125.

INTERCURRENT DISEASES. 627

during the puerperium. In my experience the fever is at first
usually continuous. As the patient is brought under the influ-
ence of quinin the fever becomes intermittent and finally dis-
appears (Fig. 467). The puerperal state predisposes to grave
forms of malaria] intoxication.

The conclusions of Bonfils, while they are in the main
correct, are not absolutely true. Exceptions are met with to
almost every one of his propositions. For instance, 1 have
seen malarial fever in the puerperal state, proven by the dis-
covery of Councilman's bodies, pursue the mildest possible
course, with very slight and irregular fever, which was easily
controlled by the administration of quinin in small doses. On
the other hand, the very worst example of malarial infection

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With which I have ever had to deal broke out in the last month
of pregnancy. The patient had already, during the previous
eight months, had two attacks of malarial fever Within a week
or two of term, the disease again made its appearance in a very
grave form. There were congestive chills, a temperature run-
ning to 104° and over, and finally profound unconsciousness.
The fever was almost continuous in its type. In the midst of
the disease labor came on, and after some difficulty the child
was extracted by the breech. After delivery the symptoms be-
came even more grave. It seemed that the woman's death was
inevitable, but by the administration of se\'enty to eighty grains
of quinin in the twenty-four hours for several days, the fever
was conquered and the woman made a rapid recovery.

PATHOLOGY OF THE PUERPERWM.

^S^:

DUsbobIs. — The diagnosis
of malaria in the puerperal state
usually presents many difficul-
ties. If it were true, as has
been asserted, that the fever is
always characterized by distinct
periodicity, the difficulty would
in great part disappear, but no
one who has had much ex-
perience can admit the truth of
this assertion. The main dif-
ficulty is to distinguish the
fever of sepsis from that of
malaria. In doubtful cases it
is a good plan to administer
large doses of quinin, and at
the same time to disinfect thor-
oughly the genital canal. If
this plan is followed by imme-
diate improvement, it is always
difficult to say whether there
was in reality malarial infection,
or whether the improvement
was brought about by the dis-
infection of the parturient tract
The microscopic examination
of the blond should clear up
many a doubtful case. The
ivhole subject of malarial fe\'er
in the puerperal state has been
discredited by the tendency to
conceal cases of puerperal in-
fection under this name. The
practitioner should always be
upon his guard in this respect
While not so satisfactorj- to
him, it is far safer to his patient
to err in the opposite direction
— to regard a doubtful case of
fever during the puerperium as
of septic and not ofmalarial ori-
gin, unless the proof in support
of the latter belief is convincing.

Treatment. — In the majority
of cases larger doses of quinin

INTERCURRENT DISEASES, 629

are required than under other circumstances. Reference has
been made to a case in which, on the average, seventy-five
grains were administered in the twenty-four hours for several
successive days. In another case under my observation, forty-
five grains a day were given for a long time, with success in con-
trolling the fever and with no ill effect upon the patient. Several
times an attempt was made to reduce the dose to thirty grains,
but the reduction in the quantity of the drug was always followed
by the reappearance of the fever. It was at one time erroneously
taught that quinin administered to a nursing woman had a dis-
astrous effect upon her milk. Runge states definitely that quinin
may be given without hesitation to nursing women. Even in
very large doses it does not pass into the milk. My own experi-
ence is in accord with this statement.

Rheumatism and Arthritis. — Arthritis in the puerperal
state is either a manifestation of septic infection, with a localiza-
tion of the septic inflammation in a joint, or else, as a rheumatic
arthritis, is simply an accidental intercurrent affection. Accord-
ing to Celles,^ Charcot, in his doctorate thesis, published in
i^53» ^'2is the first to call attention to rheumatism in the child-
bearing woman. During the following year, Simpson in Great
Britain, and Virchow in Germany, in their works upon the
puerperal state, mentioned articular rheumatism as one of its
complications. The subject has since been studied by Peter,
Loisin, Simon, Vaille, Braunbcrger, Boillereault, Tison, Quin-
quaud, Lacassagne, Hanot, Pinard, Siredey, Charpentier, Alex-
andre, ^ Hamill,^ and others. The diagnosis between septic
arthritis and simple acute rheumatism is not always easy. In
the latter, during the puerperal state one sees all the character-
istic symptoms of the affection, just as under any other ordinary
circumstances. Inflammation of the joints following septic
infection, on the other hand, presents certain peculiar signs.
The joint affected is usually a large one, very often the knee ;
the inflammation is not fugacious ; ^ it is exceedingly stubborn
in its resistance to all treatment ; the duration is usually pro-
longed, and in many cases there follows a complete ankylosis
of the joint. There may be very little evidence of general
septic infection. The arthritis may make its appearance late in

* Marcel Georges Celles, "Du Rhumatisme articulaire pendant I'^tat puer-
peral," "Thdsede Paris," 1885.

* For extensive bibliography see Celles, loc. cit.; F61ix Barral, •* Contribution ^
fetude du Rhumatisme puerj^^ral," "Th^se de Paris," 1885; Tamier et Budin,
•* Traits de I'Art des Accouchements," t. ii, p. 270.

» **Amer. Jour, of Obstetrics," 1888, p. 317.

* There are, however, occasional exceptions to this rule (Barral, loc, cit.).

630 PATHOLOGY OF THE PUERPERIVM.

the puerperal state. It may be accompanied by very moderate
Tever of an irregular type. It is more apt to appear in women
who have had gonorrhea. In the worst cases of general septic
infection the joints may be the seat of metastatic abscesses as well
as other portions of the body ; but in these cases the symptoms
pointing to a general septic infection are so plain as to indicate
at once the origin of the malady. There is one factor which
sometimes adds to the difficulty of diagnosis between acute
articular rheumatism and a septic arthritis. A metastasis has
been witnessed from the joints to the peritoneum in a case of
rheumatism during the puerperal state.' Such an occurrence
would indicate that the case was septic, and that the peritonitis
and the joint disease had a common origin in a grave form of
septic infection.

Prosnosls. — The average duration of the septic arthritis is

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puerpera with fever and uterine (endemess,
ignlloii and cureltHtjc of the uterus bail na
lediately to the ■■alicj'late of scnljum. There
ism Jurtne pregnancy.

about three months. Recovery is the rule, but with an ankylosed
joint (sixteen times out of twenty-three (Tison) ). In scrofulous
subjects the affected joint may become the seat of a tuber-
culous inflammation.

Treatment. — General medication is of little use. The salicy-
lates are of no value. Local treatment, in the shape of counter-
irritation (iodin, blisters, cauterization), may hasten the cure.
If tJie inflammation is acute, soothing JotiiHis must be used.
The joint at firi^t should be immobilized, but later a cautious
employment of massage and passive motion may prevent anky-
losis.

INTERCURRENT DISEASES. 63 1

Muscular rheumatism may complicate the puerperal state. If
the disease affects the uterine muscle and is associated with
much fever, the only means, practically, of distinguishing be-
tween this affection and puerperal infection with septic inflamma-
tion of the uterus is the therapeutic test — ^the administration of
a salicylate.

Gonorrhea. — The frequency of gonorrheal infection in the
puerperal state depends upon the class of society to which the
women belong. In the lower classes, seen in dispensary prac-
tice, it is very common. In the upper classes it is decidedly rare.
The proportion of cases varies, too, in different localities.
Noeggerath and Sanger ^ report that among 1930 gynecologi-
cal cases during a single year, in private and polyclinic practice,
230 (twelve per cent.) owed their sufferings to gonorrheal infec-
tion. Among 398 pregnant women, 100 had a purulent discharge,
presumably from gonorrhea (twenty-six per cent.) ; forty of the
children developed blennorrhagia. This estimate is too high to
be correct as an average.

The differential diagnosis between gonorrheal and puerperal
infection is, according to Sanger, to be made by the following
signs : The progress of the disease in the former instance is
slower. It very rarely appears in the early part of the puer-
peral state. It breaks out first about six or seven weeks after de-
livery. The most violent cases observed by Sanger were acquired
during the period of uterine involution. It is difficult to draw
in all cases a sharp distinction between infection by gonococci and
infection by the other pathogenic micro-organisms which can
occasion local inflammation in the genital tract. On the one
hand, there are many of the infectious bacteria which can cause a
severe inflammation of the mucous membrane along the whole
extent of the canal ; and, on the other hand, the poison of gonor-
rhea can, without doubt, excite inflammation of the deeper tissues
in this region, and is quite certain, if it spreads through the
tubes, to light up a sharp attack of peritonitis. The diagnosis may
be made with approximate certainty if the disease existed during
pregnancy, or if a careful examination detects an inflammation
of the urethra and of the vulvovaginal glands, or if it is possible
to isolate the gonococcus. The consequences of gonorrhea in
the puerperal state may be of the most serious nature. There is
often a mixed infection, the gonococci preparing the way for
streptococci or other pathogenic micro-organisms. The local
inflammation, under any circumstances, may take on a very acute
character, and may be accompanied by violent peritonitis. There

* •* Ueber die Beziehung der gonorrhSischen Infection zu Puerperalerkrankun-
gen," ** Wien. med. Blatter," 1886, S. 902.

632 PATHOLOGY OF THE PUERPERIUM,

may be a rapid accumulation of pus in the tubes in the course
of the disease during the puerperium, which, however, can
occur just as well in the course of an ordinary septic endome-
tritis after labor.

Skin Diseases. — The diseases of the skin which make their
appearance during the puerperal state, and are apparently de-
pendent upon that condition for their origin, are often a manifes-
tation of septic infection. This is certainly true of erythema.
It would appear to be true also of cases of pemphigus, which
rarely occur after delivery. This disease ^ usually breaks out
on the third or fourth day of the puerperal state. It may or
may not be associated with some rise of temperature. In one
case the contents of the blebs had a distinctly fetid odor. The
duration of the disease is protracted. It lasts, on the average,
perhaps ten weeks. It would be well in such cases to adopt at
once thorough disinfection of the genital canal, because in all
likelihood the poison of the disease finds an entrance into the
body by this channel. Any other form of treatment seems to
be of little avail. The woman's general condition may be weak,
and she may need stimulants. The distressing itching or burn-
ing of the skin which sometimes accompanies the disease is
relieved by a weak carbolic acid solution.

Diastasis of the Atxlominal Muscles in the Puerperal State.
— If the uterus has been much distended during pregnancy, and
if the abdominal muscles during labor have been called upon
to exert an unusual amount of force, there may occur a wide
separation of the recti muscles, leaving space between them for
a hernia of the abdominal contents. Prochownick ^ has reported
two interesting cases of the kind. There was suddenly developed
during the puerperium sharp abdominal pain with nausea and
vomiting. Careful examination excluded puerperal infection, and
detected the protrusion of coils of intestine between the recti
muscles. The hernia was easily reduced, and a recurrence was
prevented by a comj)ress and adhesive strips. In both instances
the symptoms yielded at once to this treatment. The accident
is not likely to be a common one among English-speaking people
and in countries where the use of the abdominal binder after
labor is a universal custom.

Flatulent Distention of the Abdomen (Tympanites). —
There occurs occasionally in the puerperal state an extreme

^ Croft, ** A Case of Pempliiirus Recurrinjr after Four Consecutive I^lwrs,"
** Lancet," London, 1SS7, ii, 85S; Wood, "A Case of Postpartum Pemphigus/*
ibiii.^ iSSS, ii, 46S.

2 <« 1 >ic Dia^la^e der P»auchniiiskeln im Wocbenbett," ** Archiv f. Gyn.,"
xxvii, 419.

INTERCURRENT DISEASES, 63 3

distention of the abdomen, due to the overdistention of the
intestines with gas. The cause of the flatulence is a partial or
complete paralysis of the muscular coat of the intestines
without peritoneal inflammation. A firm binder, turpentine by
the mouth, and asafetida by the bowel will suffice in cases of
moderate degree. I have had a successful result in some very
alarming cases by giving a grain of calomel every half hour
until six grains were taken ; two hours after the last dose of
calomel a quarter of a grain of elaterium, and two hours later
an enema of an ounce of glycerin, a half ounce of turpentine,
a half ounce of Epsom salts, and two ounces of water. Large
doses of strychnin hypodermatically are necessary to the suc-
cess of this treatment. In the worst cases the only remedy
which affords relief is a puncture of the large intestine with a
fine trocar. This procedure appears to be devoid of danger.
It has long been applied in the treatment of animals, especially
sheep, to relieve flatulent dyspepsia. It has also been adopted
with good results in human beings. ^ In one recorded instance
the bowel was tapped twenty-eight times without bad result.
On one occasion I saw a complete paralysis of the intestinal
coats after a twin labor. The woman's abdomen was opened,
and the small intestines punctured with a knife in a number of
places. The punctures were carefully closed after giving vent
to all the gas and feces that would escape. The relief was only
temporary. The woman died on the following day.

There are many other acute and chronic affections besides
those already described which may complicate the puerperal
state. They are, however, purely accidental complications,
which neither produce a distinctive change in the course of the
puerperium nor are themselves modified by the woman's condi-
tion. As examples of the kind might be mentioned dysentery,
intestinal parasites, ^ appendicitis,^ miliary tuberculosis,^ acute
pancreatitis,^ miliary fever, hepatic colic, ^ and gangrene of the
ileum,'' besides many more, the list of which includes almost
all the pathological conditions to which the adult female is
subject.

* Priestley, " Note on Puncture of the Abdomen for Extreme Flatulent Dis-
tention,'* "Lancet," London, 1887, i, 718.

' ** Indian Medical Gazette," xxii, 240.

* Dearborn, *♦ Vermiform Appendicitis and General Peritonitis Complicating the
Puerperal Period."

* "Centralbl. f. Gyn.," 1885, ix, 417.

* Ibid. , 1884, viii, 609.

•*• Ann. Soc. d'Hydrol. m6d. de Paris," 1887, 169.
» " Frauen-Arzt," Berlin, 1886, i, 308.

634 PATHOLOGY OF THE PUERPERIUM,

Diseases of the Urinary System. — ^The Urine. — Gassner*

was the first to point out that the excretion of urine after
delivery is very much increased. Winckel comes to the fol-
lowing conclusions in regard to the quantity of urine excreted
and to the modifications in its constituent parts during the puer-
perium : During the first two days the increase in quantity is
most marked. The fluid is clear and of a light-yellow color.
The specific gravity is very low. The absolute quantity of urea,
phosphates, and sulphates is somewhat diminished, but the
amount of sodium chlorid is not altered. The urine during
the progress of uterine involution gradually regains its normal
quality. The average amount of urine passed in the first six
days is ii,i6o grams. The average specific gravity is loio.
The quantity passed upon each day averages as follows : The first
day, 2025 c.c. (74.4 fl. oz.) ; the second day, 2271 c.c. (76.5 fl. oz.) ;
the third day, 1735 c.c. (58.6 fl. oz.) ; the fourth day, 1772 c.c.
(59.8 fl. oz.) ; the fifth day, 1832 c.c. (61.9 fl. oz.) ; and the sixth
day, 1949 c.c. (65.8 fl. oz.). It is not at all rare to find albumin
in the urine ^ shortly after delivery, but as it is only a temporary
phenomenon, disappearing within forty-eight hours, as a rule
(Blot, Ingersley, Lantos), and seems to exercise no injurious
influence upon the woman's condition, it may be regarded as
practically a physiological occurrence. Maguire ^ compares the
albuminuria of the puerperal state with the cyclical albuminuria
met with under other circumstances, and says that very likely in
both these conditions the precipitate with nitric acid and heat is
globulin, and not serum albumin.

The appearance of sugar in the urine after delivery is also a
very common occurrence, which has been attributed to the ab-
sorption of lactose from the mammar)'^ gland ; indeed, one ob-
server declares that the quantity and quality of the milk may be
judged by the amount of sugar in the urine.'* Rut, as a matter
of fact, glycosuria is more common when the milk -secretion fails
than when the supply is most abundant^ Curiously enough,
the amount of urea in the urine does seem to depend on the ex-
cretion of milk ; the former increases with the increase of the

MVinckel, •* Pathol, u. Therap. des Wochenl^ttes," p. II.

2 I!\ainiiiin}T the urine of 600 puerpera directly aft^ delivery, I^ntos found
albuiniimri.i in 5<).33 percent. This is a more common occurrence by one-third in
primipar.v tlian in muitipane (•* Beitrage zur Lehre von der Kklampsie und Albu-
minuric," "Archiv f. (lyn.," Bd. xxxii, p. 365).

^ ** Palholoj^y of Puerperal Albuminuria," London *' Lancet," Sept. 18, 1886.

^ Blot, ''('oniptcs Koiulus," xliii, p. 676.

■^ H()fIn(M^ter, ♦' Zoitschr. f. phys. Chemie," Bd. i, S. 703; Johannovsky,
"Archiv f. (iyn.," Bd. xii, S. 44S. A full bibliography on this subject may be
found in SchrDcder's ** GcburtshUlfe,'' lo. Aufl. , p. 236.

DISEASES OF THE URINARY SYSTEM. 635

latter.^ This statement would also seem to hold good of the
phosphates and the sulphates, which increase with the urea and
with the excretion of milk.? The appearance of peptones in
the urine of recently delivered women is quite constant. The
following statements in regard to it appear to be justified : ^

1. Peptonuria is constant in the puerperal state. The quan-
tity of peptones, however, in individual cases varies consider-
ably.

2. The urine contains usually no peptone on the first day,
but thereafter until the fourth day the quantity increases steadily,
then begins to decrease, and disappears on the twelfth day.

3. The peptonuria is probably the result of the direct con-
version of the uterine muscle into peptone.

4. After the delivery of macerated infants, one finds no pep-
tone, or only a very small quantity.

5. Occasionally, peptone is found during the latter days of
pregnancy. In these cases peptonuria can be demonstrated
directly after birth and in the first day of the puerperium, but
in lesser quantities than in other puerpera?.

6. The difficulty of a labor and its length exercise no in-
fluence upon the peptonuria.

7. The peptonuria stands in direct relation to the involution
of the puerperal uterus.

8. The specific gravity of the urine is in direct relation with
the quantity of peptone in it.

9. The peptones formed in the uterus behave in the blood
like the digestion peptones, or like the peptones that are arti-
ficially introduced into the circulation.

10. The quantity of the peptones in the urine is in direct
ratio to the number of white blood-corpuscles in the blood of
the individual puerpera.

The lochia may also contain peptones, but independently of
the peptonuria, and without influencing the quantity of peptones
in the urine. A careful examination of the uterus and its lining
membrane after delivery demonstrated that in the uterine muscle
considerable quantities of peptones could be discovered, while
in the lining membrane this substance could not be found.*
Fischel declared that he found peptones in one-quarter of all the

* Grammatikati, *• Ueber die Schwankungen der Stickstoffbestandtheile des
Harns in den ersten Tagen des Wochenbetles," * * Centralblatt f. Gyn.,*' 1884, p. 353.

^ Grammatikati, op. cit.^ p. 467.

* Fischel, •* Ueber puerperale Peptonurie," '*Archiv f. Gyn./' 1884, xxiv,
p. 400, and ** Neue Untersuchungen iiber den Peptongehalt der Lochien nebst Be-
merkungen Uber die Ursachen der puerperalen Peptonurie." ibid.^ 1885, xxvi, 120;
Biagio, ** La Peptonuria puerperale," " Ann. di Ostet.," 1 887, ix, 202.

^ Fischel, ioc. cit.

636 PATHOLOGY OF THE PUERPERIUM,

cases of pregnancy examined. If the urine after labor contains
albumin in considerable quantities and persistently, it is evidence
of trouble in the kidneys. There are usually associated with
persistent albuminuria other symptoms indicating kidney disease.
One of these is acute pain, most often in the head, but sometimes
referred to the epigastrium or to other regions of the body.^
There may be edema. There is found in the urine microscopical
evidence of degenerative changes in the renal epithelium. Albu-
minuric retinitis is not a ver}'- uncommon accompaniment of
kidney disease in the puerperium, and may induce complete
blindness, but it should be remembered that there may rarely
occur a temporary blindness in the puerperal state independent
altogether of kidney disease.'^ It usually comes on shortly after
deliver)', and lasts for a few days. Typical examples have been
reported by Brush and by Konigstein. The latter attributes the
accident to a spasmodic condition of the retinal vessels traceable
to a vasomotor disturbance. The loss of vision may follow
severe hemorrhage or eclampsia, may be associated with albu-
minuria, or may be the result of a septic panophthalmitis.
Konigstein suggests, as a treatment for the temporary' blindness
due to a spasmodic action of the retinal vessels, the inhalation
of amyl nitrite. The woman's nerv^ous system exercises a pow-
erful influence on the composition of the urine. Cameron * has
reported an extraordinary case of high temperature and glyco-
suria in the puerperal state, the result of nerv'ous influences.
The tcmjx-Mature rose during waking hours and fell during sleep,
without corresponding variation in pulse. The glycosuria seemed
to have direct connection with the ner\'ous phenomena, and lasted
only a slu)rt time.

Hematuria, when seen in the puerperal stiite, has almost in-
variably persisted from i)regnancy. In these cases there are usu-
ally bleeding hemorrhoids of the bladder, due to the mechanical
interference with the i)elvic circulation by the presence of the
gravid w(Mnb. The blood disappears from the urine in a few days
after dclixer)'. In bad cases of septic infection of the vesical
mucous membrane, as a result of injur}' with instruments, or as
a consequence of vesicovaginal fistuLe, the same symptom may
appear, but the differential diagnosis is easy. Renal and vesical

Mvavcn, *• Xott.' 011 Puerperal Albuminuria,'' ** Lancet," London, 18SS, ii,
715; Phillips, "Acute Lpigastric Pain in the Puerj)eral Albuminuria," ibUi.^ iiv5^7,
i, 676.

- P)rusb, '*A Case of Teniporar>' Pliiidness followinjj Child-birth," *' Obstet.
Cia/ettc," vii, 1884; Koni^>tein, " I'rblinduni^ nach einer (ieburt in Folge von Isch-
emia Reliniv," "Wiener med. lV<>^e," 1885, xxvi, 585.

* " Ili^h Tem]>eralurc and (Ilyrosuria in the Puer]H*ral State, the Result of
Nervous Inlluences,'' " Mcmtreal Med. Jour.," Jan., 1889.

DISEASES OF THE URINARY SYSTEM. 637

calculi and malignant tumors of the kidney and bladder are pos-
sible causes.

The Kidneys. — Hervieux divides the diseases of the kidneys
in the puerf)eral state under four heads : First, inflammatory
nephritis ; second, metastatic nephritis ; third, evanescent albu-
minuric nephritis ; and fourth, subacute albuminuric nephritis.
In the first stage of inflammatory nephritis one finds hyperemia
and tumefaction of the organ. Very often this condition is
associated with general septicemia. If the disease develops
primarily in the puerperal state, it is very likely a manifesta-
tion or an accompaniment of general septic infection, and will
often be undetected in the midst of other complications present-
ing more obvious and more alarming symptoms. An intense
hyperemia of the kidney associated with septic infection may
result in an apoplexy of the organ. Metastatic nephritis is, of
course, the result of septic infection. In the evanescent albu-
minuric nephritis the kidney is increased in size. Its surface is
smooth ; the fibrous tunic, thickened and injected, is easily
stripped off. The increase in the size of the organ is due prin-
cipally to the tumefaction of the cortical substance. In the
fourth variety of kidney diseases in the puerperal state the course
is a more tedious one, and the disease may pass into chronic
nephritis. Maguire asserts that the lesion most commonly found
in cases of puerperal albuminuria is one of anemia of the kidney
with fatty degeneration. Lantos,^ in the records of 39 post-
mortem examinations of puerperae who had neither died from
eclampsia nor nephritis, found in 1 5 cases the kidney described
as "anemic," in 21 **pale," and only in 3 ** congested." Among
16 women who had presented symptoms of kidney disease there
were found twice acute parenchymatous nephritis, once acute
hemorrhagic nephritis, nine times parenchymatous degeneration,
and four times albuminoid degeneration.

Incontinence of Urine. — There may be an involuntary escape
of urine after labor in consequence of an overfilled bladder, of
paresis in the sphincter muscle, and of a perforation communi-
cating with the vagina or some portion of the genital tract.
The first cause, the overflow of retention, should always be sus-
pected and looked for, as it is the most common. The treat-
ment varies with the cause of incontinence. The use of a
catheter removes the difficulty in cases under the first cate-
gory. Cases of the second group are more difficult to deal
with. The partially paralyzed muscle, as a rule, regains its
tone in a short time. It may be possible to hasten recovery in

* Loc, cit.

#
638 PATHOLOGY OF THE PUERPERIUM,

a chronic case by the administration of tonics, the use of local
astringents, or, perhaps, by the application of electricity. The
preventive treatment should never be neglected. These cases
almost invariably follow delayed and difficult labors with head
presentations. A timely interference, therefore, would save the
woman the discomfort, and even danger, of a constant dribbling
of urine over the external genitals. ^

Cases of the third order should be managed by attempting
to obtain a primary closure of the fistulous opening. This can
be effected in some cases, if the fistula is not too large, by touch-
ing its edges with a strong caustic — nitric acid.

Cystitis. — Cystitis is^ unfortunately, a common occurrence in
the puerperal state. It is due, in the vast majority of cases, to a
careless, clumsy, or ignorant use of the catheter. The old plan
of introducing a catheter under the bed-sheet is responsible for
a large number of these cases. If physicians and nurses would
catheterize a patient with an aseptic instrument, after careful
cleansing of the vestibule and by the sense of sight, there
would be very little risk indeed of infecting the bladder mucous
membrane by the use of the catheter. A transitory inflamma-
tion of the bladder may be due to long-continued pressure or to
injury during birth, but such cases are rare. The cystitis is
almost always a septic disease following the infection of the
bladder mucous membrane. ^ It is possible that micro-organ-
isms may migrate from the vagina along the mucous membrane
of the urethra to the bladder without the intervention of cathe-
terization. In order that the micro-organisms, having gained
access to the bladder, may bring about an inflammation of the
vesical mucous membrane, it is necessary to have a condition of
that tissue favorable to the invasion and to the growth of the
bacteria. The invasion is much facilitated by a solution of con-
tinuity in the mucous membrane. It is also favored by a re-
duction in the vitality of the vesical epithelium, which follows
prolonged pressure upon the bladder during labor, or is a con-
sequence of the ovcrdistcntion of the bladder-walls from pro-
longed retention of urine. There is a disposition of the inflam-
mation in many cases to spread rapidly toward the kidneys, so
that after the bladder affection is cured the kidney disease re-
mains. There may be intermissions for some length of time of
api)arcnt health between the infection of the bladder and the
outbreak of disease in the pelvis of the kidney. The termination

^ l{iHlin(kri,'iie-l,a£Tr^ze. *' Incontinence d'Urine sans Fistule consecutive ^
rAccoucliemcnt," " TIk^sc de Paris," 1886.

* ** Die -I'tiolopie dcs ])iuTperaUMi Blasenkatarrhs nach Beobachtung an Woch-
nerinnen und Thierversuchen," " Centrall)lalt f. Gyn.," 1886,443.

DISEASES OF THE URINARY SYSTEM. 639

of cystitis after delivery is, in the vast majority of cases, favor-
able. The inflammation may, however, persist for a long time,
and may become, perhaps, an inveterate chronic affection. In
the worst cases of septic cystitis the disease manifests most
alarming symptoms and may end fatally. ^

There may be a thick, diphtheric infiltration of the mucous
membrane, which is finally exfoliated and discharged by the
urethra in thick masses. In other cases, again, the mucous
membrane becomes gangrenous, and is finally expelled in frag-
ments of varying size along with the urine. Pieces of the infil-
trated mucous membrane lying loose within the bladder may
obstruct the outflow of urine. In these extreme cases the urine
is full of pus, blood, albumin, and renal tube-casts, and has a
horribly fetid odor.

Treatment, — Every case of cystitis after labor should be
treated energetically and without delay, for fear of a spread of the
infection to the kidneys. A daily irrigation of the bladder by a
quart or more of boric acid solution (gr. xv-5j), a milk diet,
and boric acid by the mouth arc usually sufficient, if ordered
immediately, to stamp out the disease in its incipiency. Vaginal
cystotomy is required in severe cases for drainage.

Pyelonephritis. — An inflammation of the pelvis of the kidney
may follow infection of the bladder by an extension of the
disease along the ureters. This is true of the vast majority of
cases, but in some instances the bladder disease may be of such
a transient nature that it passes undetected, and the physician's
attention is first attracted by the subsequent pyelonephritis. It
is possible that the infection in a case of pyelonephritis may
occur in the kidneys from the blood. The disease may also
follow mechanical irritation from renal calculi. I have seen
one case of pyelonephritis during the puerperal state which was
associated with renal calculi. There was a sudden exacerba-
tion of the disease some few days after labor, associated with a
high fever and a suppression of urine. The attack passed off"
in the course of forty-eight hours, however, and the woman
finally recovered. The treatment of pyelonephritis of septic
origin consists in stimulation, support, the administration of
bland diuretics, and irrigation of the bladder. Occasionally, it is
necessary to incise the pelvis of the kidney by the lumbar route
and to drain it for a while. The ureter is washed out from above
downward, and finally the urine is allowed to take its natural
course. I have seen this plan of treatment carried out twice
with success. In two other cases the infection spread from the

1 Boldt, •* Cystitis Suppurativa Exfoliata Puerperal is," *' N. V. Med. Record,"
1885, ii, 497.

640 PA TIIOL OGY OF THE PUERPERIUM,

kidney to the perirenal fat, producing perirenal abscesses, that
were opened by lumbar incisions. The outcome of a pyelo-
nephritis is dubious. A large proportion of the cases under my
observation have died. The kidney after death was found to be
either a large bag of pus or else was riddled with innumerable
minute abscesses.

Diseases of the Nervous System. — For the psychoses and
the neuroses, see page 233.

Lesions of Sacral Plexuses; Neuritis and Nerve Degeneration
from Pressure During Labor. — These complications are usually
seen in a justominor pelvis or in one with a slight projection of
the promontory, which affords insufficient protection to the nerve-
trunks on cither side of it. Puerperal paralysis may result.
Both limbs may suffer (paraplegia), or there may be unilateral
paralysis, with atrophy and anesthesia. The leg or legs may be
the seat of constant pain, and may be very hyperesthetic.
Pressure upon the sciatic ner\'e or movement of the afifected limb
may cause agonizing pain, or there may be intense and persistent
pain in the pelvis, unassociated with disease of the sexual
organs. Pressure with the finger in the rectum upon the sacral
plexus causes exquisite suffering. The same results may follow
pressure from exudates or the involvement of the nerve-trunks
in septic inflammations. Fixation and extension of the limb
give the greatest relief at first. When the acute stage has
subsided, massage, electricity, and passive movements hasten the
restoration of the limb to usefulness. The prognosis is fairly good.
There may be, directly after child-birth, neuritis of nerves distant
from the genital region (the ulnar, for instance). Multiple
neuritis in alcoholic subjects may develop after child-birth or
during pregnancy. I^iury ^ makes three divisions of puerperal
neuritis — traumatic, septic inflammatory by extension, and infec-
tious neuritis of distant nerves and of the spinal cord.

Apoplexies of the Brain and Spinal Cord ; Aphasia ; Hemiplegia ;
Paraplegia. — There is a predisposition to apoplexies in the central
nervous .system during labor, especially in women whose vessels
are diseased in con.sequence of insufficient kidney-excretion.

Ascending Myelitis — I have seen an ascending myelitis first
manifesting itself some two weeks after labor, the temperature
having been previously normal, but becoming elevated as
paralysis of the lower limbs appeared. The paralysis was pro-
gressive, and the result fatal. At the postmortem examination
no starting-point in a septic focus or apoplexy could be
discovered. There were simply the signs of inflammation and

* "Archives de Tocol.," Nov. I, 1893.

ANOMALIES OF THE BREAST. 641

degeneration. It is an interesting inquirj' whether this condition
conld have come from pressure upon the lumbosacral plexus
and an ascending nerve-degeneration.

Developmental Anomalies of the Breast. — Absence of
Mamms:. — Complete absence of both breasts is one of tlie rarest
anomalies of development. Marandel, Lousier, and Froriep '
each report a case of entire absence of one breast, the other
being well developed. Imperfect development of the mammarj'
glands is common. It is sometimes
seen to an extreme degree in cases
of infantile or absent sexual organs.

Hypertrophy of the mammie is
also rare. Labarraque ^ collected
twenty-six cases, of which only five
were over twenty-sbc years of age.
The breasts are usually asymmetri-
cal. There is one case on record
in which a single mammary gland
weighed sixty-four pounds. Lacta-
tion lias been known to diminish
a congenital hypertrophy of the
breasts. An overgrown mammary
gland, therefore, is not a contrain-
dication to suckling the child.

Supernumerary Breasts — Poly-
mastia.— Supernumerary breasts and
nipples are more common than is
generally supposed. Bruce found
60 instances in 3956 persons ex-
amined (1.56 percent.). Leichten-
stern places the frequency at i in
500. Both observers declare that
men present the anomaly about
twice as frequently as women. In
400 women examined in one winter
in my hospital services there was 1
case of polymastia. It is impossible
to account for the accessory glands
m, as they occur with

Kig. 470.-

I the theory of rever-
I regularity in situation, but may
develop at odd places on the body. The most frequent position
is on the pectoral surface below the true mamma and somewhat
nearer the middle line; but an accessory gland has been observed

642

PATHOLOGY OF THE FVERPERIUM.

on the left shoulder over the prominence of the deltoid ; on the
abdominal surface below the costal cartilages ; above the umbili-
cus ; in the axilla ; in the groin ; on the dorsal surface ; on the
labium majus ; on the buttock, and on the outer aspect of the
left thigh. In cases reported by Edwaids ' and Handyside, and
in some others, including one of the author's, heredity seems to
have been a probable explanation for tlie development of the
supernumerary mammse ; but in the vast majority of cases no
hereditary influence can be traced.

Ahlfeld ^ explains the presence of mammae on odd parts of
the body by t!ie theory that portions of the embryonal material

entering into the composition of the mammarj' gland are carried
to and implanted upon any portion of the exterior of the body
by means of the amnion.

The woman represented in figure 47 1 is remarkable for the
almost unprecedented number of breasts and nipples that she
She has nine mamma; all told, and as many nipples.

I '• Medical News," March 6, 1S86 (ijood bibliography). See also Golilberser
("Arcliivf. Gyii.," »li>l. H. 2, S. 27a), who slates liial Ihcre are J6l cases rei-iirdMl
in lileralure. ' " MissbildunB"! der Menuhcn."

• NeURebnuer bas reported a case of polymaslia wilh ten nipples. ■' Onlral-

bUlt f. Gyn,,'' 18S6. No. 45.

ANOMALiES OF THE BREAST. 643

everyone of which secreted milk profusely. The two normal
glands are very large. The nipple of the gland in the left
axilla is not shown very plainly in the illustration on account of
its situation, and it is not easy to see it in the woman herself,
concealed as it is by the axillary hair, but when tlie correspond-
ing gland in the axilla is compressed, a stream of milk may be
projected several feet from the woman's body.

As may be seen, the glands are arranged with some symme-
try. There are five on the left and four on the right side.

The woman is a negress, nineteen years old. and a IV-para.
Her child was born prematurely. Her mother had a

Fig- 4J2-— ^upei
bullock, li wa» alwa
(iiutbor*»ciue).

mamma on the abdomen that secreted milk during periods of
lactation.

Anatomical Anomalies ot the Nipple. — The shape of the nipple
may unfit it for nursing, predisposing to injury by the child's
gums, to fissure and ulcerations (see Fig. 473), or making it a
mechanical impossibility for the child to take hold, as in inverted
nipples (Fig. 473). The nipples should always be examined
during pregnancy. If they are inverted, a systematic attempt
shoidd be made during the la.st month to draw them out witli a
breast-pump. Should this attempt fail, a ntppie-shield might
enable the child to nurse.

644

PATHOLOGY OF THE PUERPERIVM.

Abnormalities of the Breasts and Anomalies in the Milk i

Secretion.— Milk secretion begins usually forty -eight hours after '
delivery. Previous to this time a thin fluid can be squeezed from
tile breast, containing large cells, within which are contained many
fat-globules. To this substance the name " colostrum " has been
given, and these cells are called colostrum corpuscles. It is
always difficult to estimate the e.vact quantity of milk secreted.
The best way is to draw the milk with a breast-pump at regular
intervals during the twenty-four hours ; but the breast-pump docs
not excite maternal emotion, and. therefore, it always draws a less
quantity than would be furnished a suckling infant, for the breast

is in some degree an erectile organ, and even the sight of
the child may be sufficient to produce a flow of milk. Allowing
for these errors, there will be found, at the end of the seventh day.
about fourteen ounces in the twenty -four hours. During the five
preceding days the quantity is small and variable. By the end
of the fourth week the quantity of milk .secreted in the twenty-
four hours reaches about two pints. From this time it increases
gradually until the sixth or seventh month, when about three
pints of milk can be drawn from the breast in twenty-four hours.
After the eighth month the quantity of milk gradually decreases.
A curious anomaly of milk secretion is its occurrence indc|x;ndent
of the puerperal state, as in very old women or verj- young girls.

ANOMALIES IN MILK SECRETION. 645

after operations upon the ovaries,^ at the menstrual period, ^ or
even in the adult male. ^ The most important abnormalities of milk
secretion may be grouped under two main headings — quantita-
tive and qualitative.

Deficient Secretion. — In its extreme degree this anomaly is
known as ** agalactia," complete absence of milk, which is
exceedingly rare. Winckel, in an enormous experience, asserts
that he has never seen an example — that there is always some
little milk secretion, which may, however, pass undetected with-
out close observation. There are a few recorded cases of
complete absence of the breasts. Under such circumstances, of
course, there would be after delivery complete agalactia, so that,
although this condition is doubtless one of great rarity, its occur-
rence is a possibility. Deficient milk secretion is by no means
uncommon. There are many causes preventing normal activity
in the mammary gland. Premature maternity, if the individual
is not yet fully developed, may account for it. Advanced age is
another cause assigned for deficient lactation. There is either an
atrophy of the gland or an exhaustion of it by previous activity.
The nearest approach to complete agalactia which I ever witnessed
was in the case of a woman who had her first living child at the
age of forty-three. She had been married at forty, and had had
previously two children still-born. There was in this case so
slight a manifestation of milk secretion that it might have passed
undetected without a careful search.

Perhaps the most frequent cause of insufficient milk secretion
is lack of development in the glandular tissue, which may be
hereditary, may depend upon the continuous pressure from the
clothing, or may be associated with a defective development of
the remainder of the body, especially of the genital organs.
Altmann * has called attention to the hereditary form of atrophy
in the mammary gland. In parts of Bavaria, where it has been
the custom for centuries to nourish the children artificially, the
mammary glands no longer secrete milk. In Munich, of the
women who did not nurse their infants, fifty-eight per cent, were
said to be physically unable to do so. Of the women who
nursed their children, seventy per cent, had to resort to mixed
feeding. In other parts of Germany, on the contrary, notably
in Silesia, where the custom of suckling children has been care-

' Penrose, " M. and S. Rep.," 1889, 326.

a Sin6ty, ** Trait6 de Gyn6c.," p. 955.

• "John Hunter's Notes," quoted by Barnes ; Humboldt, ** Reise in die i^iqui-
noctiale Gegenden des neuen Continents," Bd. ii, S. 40.

♦"Ueber die Inactivitdtsatrophie der weiblichen Brustdriisen," Virchow's
**Archiv," Bd. cxi, p. 318.

64.6 PATHOLOGY OF THE PCERPERIUM.

fully preserved for many generations, it is rare to find mothei
with an insufficient supply of milk.

The ability of the breast to furnish milk does not necessarily
depend upon its size, for in some cases a large organ is made up 1

Fig. 4.74. — M.immarj- glnnd of a nullipara (frot

i"). X3»-

chiefly of connective tissue, while in another apparently ill-devel-
oped the gland-tissue is abundant and the milk-supply ample.
During pregnancy the glandular iitructure of the breasts takes
on an active growth and development, while the connective tissue
decreases to a marked degree. l!' lactation is not practised.

FiR. 475 -Mammary eland of a

,ia), xsa-

there begins at once an involution of the gland, a shrinkage of
the epithelial structures, and a regrowth of connective tissue. If
involution is allowed to occur after the birth of the first child, it
is more difficult after subsequent deliveries to awaken the breast

to functional activity.

ANOMALIES I.V MILK SF.CRETION. 647

The mammary secretion, at first sufficient, may at times be
much diminished as the result of hemorrhages or of diarrhea, in
consequence of an acute febrile attacic during lactation, or of
inflammation within the gland itself Serious organic diseases
may also be a cause, and insufficient nourishment must be held
accountable in some cases. During the siege of Paris an obser-
vation of forty-three nursing women by Decaisne ^ proved that
with imperfect nutrition the total quantity of the milk is much
decreased. Almost one-third of these women lost their chil-
dren by starvation. Emotions exert an extraordinary influence
upon lactation, Those which are of gradual development and
long continuance, as profound grief, tend to progressively dimin-
ish the amount of milk. Emotions of sudden onset and short
duration, as fright or anger, either totally stop the formation of

milk, nr else so alter its constitution that it becomes a rank
poison to the child. The return of menstruation sometimes af-
fects the quantity and quality of a woman's milk, but not nearly
so often as is popularly supposed. Zweifcl states positively that
for the most part the return of the menses is without influence
upon lactation. This statement is in accord with the experi-
ence of Winckel, Joux, Tilt, Becquerel, Vernois, and my own.
There are a few other rarer causes to which deficient mammary
secretion has been ascribed. It has been said that the exit of
the milk-ducts may be obstructed by an accumulation of epi-
thelium recognized by a minute white, projecting, translucent
vesicle upon the nipple at the opening of the obstructed duct.

' " Des Modificsliuns
insulfisanle : observalions rt
liiiil. No. 2.

648 PATHOLOGY OF THE PUERPERIUM,

Nasal, pharyngeal, or bronchial catarrhs are supposed to dimin-
ish the quantity of milk. The mammary gland is described in
some cases as torpid. A failure to furnish enough milk is as-
cribed occasionally to the fact that the individual approaches the
male type. The milk -supply is rarely abundant after premature
delivery or the delivery of dead infants. It is an undoubted fact
that extreme obesity interferes seriously, if it does not almost
entirely prevent, a functional activity of the mammary gland.

Treat7He?tt. — It is obvious that no single plan of treatment
will increase a deficient milk-supply. It is also apparent that in
the vast majority of cases the cause of the difficulty is beyond
the influence of any treatment. One can not alter the age of the
patient nor replace deficient glandular tissue. There are some
cases, however, of insufficient secretion that respond promptly
to appropriate treatment. A scanty supply of milk dependent
upon an insufficient diet is easily corrected. It should never be
forgotten that when lactation is interrupted by an acute febrile
attack nursing may be successfully resumed after convalescence
is established, even though weeks and occasionally months have
intervened. I have seen lactation begun and continued success-
fully a month after a difficult Cesarean section attended with pro-
fuse hemorrhage. In cases of general ill health or constitutional
weakness, much may be effected by the administration of tonics
and nutritious diet and change of air and scene. If the deficient
secretion is dependent upon some emotion, the cause, if possible,
should be removed. Electricity has been much vaunted as a
remedy for insufficient lactation. It may be applicable in cases
of torpidity of the mammary gland or in those cases in which
lactation was not practised after the birth of the first infant, and
in which, therefore, the mammar)' gland does not respond
readily to the stimulus of subsequent births. This remedy,
however, often proves ineffective and disappointing.

There is no medicinal galactagogue of any value. If three
meals a day of food suitable to the patient's condition, reinforced
by four glasses of milk between meals and fluid extract of malt
at meals, will not produce a sufficient flow of milk, the child must
usually be artificially fed.

Quantitative anomalies by excess in the millc secretion may take
three forms. In women of a vigorous physique, well nourished,
and of a full habit, the supply of milk is likely to be in excess
of the infant's needs — polygalactia. Lactation may be continued
far beyond tlic usual time — hyperlactation. In the third variety
the milk continues to flow from the breasts in var>-ing quantities
and for varying kMunhs of time after the child has been weaned
— galactorrhea.

ANOMALIES IN MILK SECRETION 649

Polygalactia. — This condition is exceedingly common. The
treatment has been referred to on page 344. Its main features
are compression and support of the breast by a mammary
binder, the administration of laxatives, the regulation of the diet,
and the evacuation of the superabundant quantity of secretion.

Hyperlactatlon is more frequently met with among the poorer
classes. Infants are nursed far longer than they should be,
either from the fact that it is difficult to provide food for another
mouth or because of the prevalent belief that lactation grants
immunity from impregnation. Women have been known to
nurse their children up to the second or third year. Some
women and certain races do it with impunity. Spanish wet-
nurses suckle three or four successive children in one family.
Japanese women habitually nurse their children for five or six
years. Hyperlactation, however, usually leads to serious results in
the women who fall under the care of physicians in this and most
civilized countries. The patient becomes exceedingly weak and
presents all the symptoms of a serious constitutional disease.
The quantity of blood is diminished — oligemia. The woman
grows pale and thin ; there are loss of appetite, constant head-
ache, pain in the back, indisposition to make any physical effort,
and the whole nervous system is more or less seriously deranged.
Cramps in the muscles of the neck and upper extremities occur
frequently ; they appear often during the day and last for vary-
ing periods. The application of the child to the breast often
originates an attack. There is especial danger in women of
tuberculous tendencies of originating phthisis.

The treatment of hyperlactation is simple and effective. The
child must at once be weaned, and the mother's strength restored
by a nutritious diet, tonic remedies, and, if possible, change of air.

Qalactorrhea. — By this term is meant a flow of milk from the
breasts not necessarily excited by the suckling child, and com-
monly continued long after the usual term of lactation. The
quantity of milk excreted may vary from a few grams to seven
liters in the twenty-four hours. ^ Usually, both breasts are in-
volved ; sometimes the flow is confined to one side. The cause
of the anomaly is unknown. It has been attributed to a relaxa-
tion or paralysis of the circular muscular fibers surrounding the
milk-ducts, but, as Winckel remarks, this, in the majority of cases,
is an effect and not a cause. There is a case recorded, however,
of galactorrhea in the left breast, associated with the left hemi-
plegia occurring after child-birth. ^ The affection is one com-

^ Winckel, ** Path, u, Therap. des Wochenbcttes,*' p. 440.
* " Trans. I^ndon Obstet. Soc. for 1887," xxix.

650 PATHOLOGY OF THE PUERPERIUM,

monly of long duration, extending often over years. There is a
case reported in which, for thirty years, there was an uninterrupted
flow of milk from the breasts of a woman who, at the time the
report was made, had reached her forty-seventh year. Curiously
enough, this long-continued drain upon the system had had no
injurious effect upon the woman's health, which remained excel-
lent. Another anomalous feature in the case was that the return
of the catamenia increased for the time the discharge of milk. ^
I have seen a woman who had had galactorrhea for eleven years
after a miscarriage at the fifth month. Her health remained per-
fectly good. The usual effect of a long-continued discharge of
milk from the breasts is most unfavorable upon the individual's
health. It is the same that any long-continued discharge pro-
duces upon the constitution. The general debility from
this cause is known as ** tabes lactea." The same condition
may be seen in extreme cases of polygalactia and in hyperlacta-
tion.

Treatment. — The most prominent feature in these cases is the
stubborn resistance that they offer, as a rule, to treatment
There are two measures which can usually be depended upon
to gxwQ^ relief — firm compression of the mammary gland and the
administration internally of iodid of potassium. It should be
remembered, however, that in many cases the milk secretion
stops spontaneously with the return of menstruation,^ and that
in a certain proportion of cases a treatment adapted to securing
a discharge of blood from the uterus has been successful in cur-
ing galactorrhea. Routh ^ advocates Simpson's plan of intro-
ducing a piece of caustic within the uterus for securing this result
Abegg was successful in two instances in stopping the galactor-
rhea by the use of warm douches, which brought about a return
of the menses. Electricity has been recommended to secure the
proper contraction of the sphincter muscles of the lactiferous
ducts. The long-continued administration of ergot has been
successful, and its use is rational. The experiments of Roehrig *
have demonstrated that drugs which bring about an increased
arterial pressure in the breasts promote milk secretion, while
those which lower arterial tension tend to diminish or even
abolish the function. Chloral was shown to be peculiarly power-
ful in diminishing the quantity of milk ; therefore, this drug is
also worthy of a trial. Belladonna internally, or as a local ex-
ternal application, is usually employed as a routine practice, but

^ Cirecn, quoted by Ciibbons, *' A Case of ( lalactorrhea (unilateral)," ihiii.

2 (iibl)ons' case; Abei^pr's cases; in two cases, under the care of Depaul, the
galactorrl)ca was arrested l)y the recurrence of pregnancy.

^ Discussion on Ciibbons* paper, ioc. n't. * Quoted by Gibbons.

ANOMALIES IN MILK SECRETION. 65 I

it is of doubtful utility. It has been declared that antipyrin,
in 2 54-grain doses, three times a day, diminishes milk secre-
tion.^

Qualitative Anomalies in the Milk. — The most important factor
influencing the constitution of the milk is the diet. A fatty diet
diminishes the quantity of milk. A vegetable diet dirninishes
the casein and fat, and increases the sugar. A diet rich in meat
increases the fat and casein, but diminishes the sugar. A scanty
diet diminishes all the solid constituents of the milk except
the albumin.

The commonest anomaly in the constitution of the milk, in
my experience, is a deficiency of fat and an excess of casein.
In one of my patients, in each of three confinements there has
been a milk of only 0.8 per cent, fat and 3 per cent, albu-
minoids. Usually this disordered condition of the milk can not
be remedied. In a few instances, however, qualitative anomalies
may be corrected by dietetic management.

The effect of emotions upon the constitution of the milk has
already been referred to. Baranger ^ quotes a good example :
A nursing woman saw her husband threatened by a soldier
armed with a saber. Directly afterward she gave suck to her
child. It seized the nipple at first with avidity, then refused it,
became violently convulsed, and died. Every practising physician
has seen, at least to some degree, examples of the change
produced in the milk by mental impressions. Becquerel and
Vernois found that under the influence of emotion the milk of a
woman contained more water, very much less fat, and somewhat
more casein than was found in the mammary gland of the same
individual under ordinary circumstances. Almost all acute
febrile affections not only diminish the mammary secretion, but
produce some change in its constitution and make it indigestible.
This is most marked in the prodromal period. If a chill occurs,
the lacteal secretion is suspended almost entirely for from twelve
to twenty -four hours.

The germs of some diseases pass from the mother*s organism
into her milk ; this is undoubtedly true of tuberculosis. It is
probable that the germs of malaria find an exit from the body in
this way. Septic micro-organisms may contaminate the milk
from the breast, although the mammary gland itself is free from
inflammation. Karlinski ^ has reported a fatal infection of the

1 " Bull. g6n. de Th^rap.," June, 1888.

2**L€s Centre- indications et Obstacles ^ TAllaitement maternal/' *• Th^se de
Paris," 1884.

• " Tms ^tiologie der Puerperal -Infektion der Neugeborenen," " Wien. med.
Wochenschr.," 1888.

652 PA TIIOL OGY OF THE PUERPERIUAf.

new-born from the milk of a puerpera with septic fever. In the
milk were found staphylococci.

Women under the influence of mercurialism or saturnism
excrete milk of abnormal quality, dependent, perhaps, as much
upon the anemia associated with these conditions as upon the
excretion of the drug itself. The influence of syphilis upon the
constitution of the milk is not yet known. It has been asserted
that there is no change in the milk of syphilitic women. Vemois
and Becquerel, on the other hand, affirm that there are well-
marked alterations in the relative proportions of the different in-
gredients in the milk from syphilitic women.

Under ordinary circumstances colostrum -corpuscles may be
detected in human milk for the first eight or ten days after de-
livery. There are certain conditions in which a return of these
corpuscles may be noted. They reappear sometimes upon the
return of menstruation, during acute mastitis, or in any other
acute affection during lactation. Of twenty -three examinations
made by Truman ^ to investigate this point, colostrum -corpuscles
were found present in the following cases : In a primipara for
four weeks after the birth of a premature infant ; in a woman who
was suckling her four-month-old baby ; in a non-pregnant woman
whose infant, bom twcnty-si.x months before, had been weaned
for ten months ; in a non-pregnant woman who had been married
three and a half years ; ever since marriage, for a week before
menstruation, the breast filled with milk, in which were colos-
trum-corpuscles ; in a nursing woman who had never been able
to use her right breast during lactation. Her last child was
twelve months old. In the milk which could be squeezed out of
the right breast colostrum-corpuscles were discovered. Another
case was one of chronic ovaritis. Twenty-three months had
elapsed since the last labor, and eleven since weaning. The
milk which exuded from the breast contained colostrum -cor-
puscles. In the breast of a woman fifty-si.x years old, which
was removed for carcinoma, about a teaspoonful of milk was
found, very rich in colostrum-corpuscles. This woman's young-
est child was eight years old. In a case of galactorrhea which
had persisted for four years tJicsc bodies were also discovered.
The presence of colostrum-coqjuscles in the milk is not a proof.
therefore, of a recent delivery.

Diseases of the Mammary Glands. — Areola. — The glands
of Monti^omery may become inflamed, and their infection may
lead to inaniniary abscess.

Trcat)Hi)it. — Infection of the areola; should be avoided bv

1 British MimI. Jour.," 188S, ii, p. 947-

654 ■P'^ TUOLOa Y OF THE PUERPERIVM.

cleanliness. Each inflamed and suppurating gland should be
opened, curetted, and its interior touched witli strong biclilorid
solution.

Exaggerated pigmentation of the areola often persists after
pregnancy ; it fades away in the course of lactation or after the
child has been weaned.

Congestion and endorsement of the mammK occur in almost
every case on the third day. when lactation is instituted.

Trmtnieiit. — Excessive congestion may be avoided by admin-
istering a saline purge on the evening of tiie second day. The
brea.sts must be thoroughly evacuated at regular intervals by the
child's mouth, reinforced, if necessary, by massage and a breast-
pump. Hot fomentations may give great comfort; but if the
congestion and pain persist, lead-water and laudanum is the best

Fig. 479.— Brcasu djsligured tiy exaggcti

<u uf Ibc ucoIk.

application. A mammary binder is almost always a necessary
part of the treatment. The pressure and support which it affords
contribute more than any other single item in the management
of these cases to prevent excessive congestion and engorgcmcnL
From the investigations of Honigmann ^ and Ringel.' it
appears that human milk contains normally the stiphytococcus
pyogenes albus, .is well as the staphylococcus aureus. These
micro-organisms wander in along the milk-ducts from the skin.
They produce, usually, no ill results, unless the vitality of the
epithelial cells is reduced by engorgement of the gland with milk

' F. Honigmann, ■■ Kaktetiolt^ische Umersuchungen uelier Frauenmilth," In-
aug.-Diss., Breslau, 1S93,

• RinEel, '■ Uelier den KcimgehJt der Frauciitnikh," '■ManctieD. ned.
Wochenschr.," 1S94, No. 27.

AXOMALIES I.V .yiLK SECRETIOX. 655

and blood, as in the "caked breast" They may then take an
active part in the development of a mammary abscess, by attack-
ing the epithelial cells of the milk-ducts, destroying them, and
invading the surrounding connective tissue.

Sore Nipples. — Excoriations and fissures of the nipples are
due to the maceration and irritation to which they are subjected
by the child's gums and mouth. Mammary abscess not infre-
.quently results from the entrance of streptococci or of other in-
fectious bacteria through these fissures.

Prophylactic Treattmnt. — During the latter months of preg-
nancy the nipple should be washed twice a day, and should then
be touched with a piece of clean absorbent cotton, saturated with
a mixture of glycerol of tannin and water, equal parts. Alco-
holic astringents should be avoided. It is necessary, of course,
to keep the nipple clean during lactation, and to keep the skin

Fig. 480.

Nipple -shieliLfl

in a healthy condition by frequent applications of sweet-oil, until
the nipple becomes accustomed to its functions.

Qtrative- Treatment. — The nipple should be carefully cleansed
after each nursing, and one of the following remedies should be
applied to it : An ointment composed of sij each of bismuth
subnit. and castor oil ; tinct. benzoin comp.. applied directly to
the fissure. Iodoform, gr. x, to ung. zinci oxidi, gss ; ichthyol, 3j ;
lanolin, glycerin, each siss ; oUve oil, Siiss. The fissure may be
touched with a solution of nitrate of silver (gr. x to the ounce)
or with the solid stick. A nipple-shield is almost always neces-
sary. It must be perfectly clean, and should be kept immersed
in cool water while not in use. In cases of supersensitive nip-
ples, without abrasions or cracks, or if the latter are slight in de-
gree, extract of witch-hazel is an excellent remedy. Occasionally
the nipples are so exquisitely sensitive that the pressure of a night-
gown or of the bed-clothes is unendurable, although there is

656 PATHOLOGY OF THE PUERPERIUM.

no fissure, crack, abrasion, or inflammation. In such cases nerve-
sedatives internally and cocain as a local appHcation are neces-
sary. Usually, the child must be weaned.

Inflammations of the Breasts^Mastltls. — There may be an in-
flammation of the subcutaneous connective tissue, of the mam-
mary gland, of the deeper interstitial tissue, or of the parenchyma.
A septic inflammation is rarely confined strictly to one of these
locahtics. There is usually
involvement of all the tissues
in the gland

As 11 p rperal infvc-
n -organisms
f he inflam-
be of many
ties. The
1 >-mptoms of
f ti n are usu-
11> I gl t, b may be vcrj'
h gh the local
ppears to be

ANOMALIES AV MILK SECRETION,

657

to septic infection of the child's intestines by its contained micro-
organisms.

Mammary Abscess. — The pus may be located superficially, in
the gland-substance, or in the submammary connective tissue, as
postmammary abscess.

The symptoms of suppuration are uncertain. The reddened
skin, the swelling and sensitiveness of the breast, and the fever
may be due simply to intense congestion. Fluctuation is rarely
detected until late, and should not be awaited. A dusky-red hue
of the skin, and edema, with fever, are the most valuable signs of
suppuration, and should indicate an immediate incision or incisions.

Treatment, — A mammary abscess must be incised as soon as
the physician is satisfied that there may be pus within the breast.
It is much better to make an unnecessary incision than to allow
the pus to burrow through the gland
until the operation for the woman's
relief becomes quite formidable. If
the abscess is opened early, one
incision commonly suffices. If the
case is neglected, ever/ pocket of
pus must be opened and every sinus
must be drained to secure a prompt
and permanent cure. I have made
as many as eighteen incisions in the
two breasts, and have had half that
number of drainage-tubes through
the glands in a woman who had
been ill for six weeks or more with
mammary abscesses, in spite of a few
ineffective and insufficient incisions
in the breasts, made from time to
time by her medical attendant. In

incising a mammary abscess, the incisions, so far as possible,
should radiate from the nipple, so that they run parallel with
the lacteal ducts. Otherwise, a duct may be cut across and
a lacteal fistula may result. The incision should, if possible,
avoid the area of pigmentation, or should be confined wholly
within it, as the pigmentation foll&ws the cut, disfiguring the
breast (see Fig. 479). The abscess-cavities should be compressed,
after being opened, by a firm mammary binder, and they should
be irrigated with sterile water daily.

In the case of a postmammary abscess, the whole breast is
lifted off" the chest, and there are no signs of suppuration within
the gland itself. The systemic symptoms of this kind of mam-
mary abscess arc usually severe.

FJg- 483. — Pigment of the
areola following incisions (Rich-
ardson).

6S8 PATHOLOGY OF THE PUERPERIUM.

Treatment. — The incision should be made beyond the per-
iphery of the gland at the most dependent part as the woman lies
on her back, and a counteropening must be made upon the
opposite side. A drainage-tube xs passed under the gland by a
dressing-forceps, and the cavity is irrigated daily.

A salactocele is a milk-tumor due to occlusion of one of the
lactiferous ducts. It is usually of no pathological importance,
unless it should, as rarely happens, reach a large size, when it
must be tapped and drained.

Other mammary tumors, especially adenomata, may take on
a very rapid growth in pregnancy, and ma^*" become so engorged
and painful when lactation begins that their removal is necessary'.
In one of my cases an adenoma grew during pregnancy from
the size of a walnut to that of a cocoanut, and I was obliged to
excise it on the third day of the puerperium.

Relaxation of the Pelvic Joints. — The pelvic joints, after
labor, may be the seat of inflammation, accompanied by serous
exudation, and ending possibly in suppuration. In the case of
the symphysis pubis, the abscess can easily be opened and drained.
The prognosis, therefore, is good. Irf the other pelvic joints
suppuration is commonly fatal. The pelvic joints may be
ruptured by violence during labor. This accident is considered
in connection with the forceps operation and injuries to the
woman in labor. Finally, there may be, to a marked degree.
relaxation of the pelvic joints, much exaggerated beyond that
seen in almost every pregnant woman, and persisting for varj'ing
periods after delivery.

The etiology is obscure. Abnormal motion in the pelvic
bones has been seen in justomajor pelves. It has been noted
after abortion. It may be traced to a large, hard fetal head
which had stretched the joints. It occurs in justominor pelves
rather frccjucntly. It has been ascribed to obesity, to a cachectic
condition, to sudden and powerful exertion in the latter months
of pregnancy, to an unusually great circumference of the preg-
nant uterus, ^ and to previous disease or abnormality of the joint, ^

The diagnosis is easy. There is difficult locomotion, unusual
mobility in the joints, especially the symphysis pubis, and local-
ized pain.

The treatment should consist in the application of a firm
binder about the hips. Tonic remedies are often required. In
the course of a few weeks the joints usually become firm.
Occasionally, the relaxation persists for months.

J Winckel, " GehurtshUlfe," p. 873.

2 Schauta, in Miiller's ** Handbuch," vol. ii.

PUERPERAL SEPSIS. 659

CHAPTER II.

Ptierperal Sepsis*

Historical. — The history of the acquisition of our knowledge
of puerperal infection is distinctly modern. It had its earliest
beginning about fifty years ago, and dates back in reality scarcely
twenty-five years. Indeed, one may say that a true comprehen-
sion of the causes and nature of puerperal sepsis has been ac-
quired only within ten years, and that the past five years have
contributed more information on this subject than all the pre-
vious ages of medicine. Only a few years ago (1884) the late
Fordyce Barker made the following statement :

*' And so, by the microscopical researches of Tigri, Davaine,
Leplat and Jaillard, Burdon-Sanderson, Coze and Feltz, and
others, the infusoria called bacteria were discovered and found
to be a constituent of septicemic blood, and thus we have been
furnished with another element of distinction between septicemia
and pyemia. These bacteria, however, seem to be a product of
changes effected in the blood by septic poisoning, rather than a
cause of the morbid phenomena which appear in septicemia, for
the experiments of Bergman n and others have demonstrated
that, when these bacteria are alone introduced into the blood,
they give rise to none of these phenomena, and are absolutely
innocuous."

The history of medical views on the septic fevers of the
puerperium prior to the middle of the present century is a long
record of error and ignorance. From the earliest beginning of
medical literature to the present century, puerperal sepsis was
ascribed to suppression of the lochia. This dogma held undis-
puted sway until 1670, when Puzos advanced the theory that all
puerperal fevers were due to a metastasis of milk, which flowed
in the blood during pregnancy, and was normally attracted to
the breasts after delivery, but which might be drawn to other
organs or structures, especially the peritoneum, with disastrous
results. This theory found support in the reports of a number
of postmortem examinations, stating that milk had been dis-
covered in the peritoneal cavity after deaths following childbirth.

A little later English and German observers explained the
puerperal infectious fevers by attributing them to inflammations
of the womb and of the peritoneum, without accounting satis-
factorily for the occurrence of the inflammation. Occasionally,
one finds a reference to putrid fevers in the puerperium, a sug-
gestion that putrefying animal matter may occasion disease in

66o PATHOLOGY OF THE PUERPERIUM,

human bodies with which it comes in contact, an intimation of
the contagiousness of puerperal fever ; but these were mere
glimmerings of light that flickered out at once without illumi-
nating the general ignorance. Credit, however, must be given
to some of the English writers of the first half of the present
century for insisting upon the contagiousness of puerperal fever.

Three events laid the foundation of our present knowledge
of puerperal sepsis : The publication of Oliver Wendell Holmes*
paper on ** The Contagiousness of Puerperal Fever/' in 1843 ;
the observations of Semmelweiss in the Vienna Hospital, 1846-
'48 ; the publication of Sir James Y. Simpson's paper on ** The
Analogy between Puerperal and Surgical Fevers," in 1850.

The first of these papers must always remain a classic in
medical and English literature. It ended with these words :

** I have no wish to express any harsh feeling with regard to
the painful subject which has come before us. If there are any
so far excited by the story of these dreadful events that they
ask for some word of indignant remonstrance to show that
science does not turn the hearts of its followers into ice or stone,
let me remind them that such words have been uttered by those
who speak with an authority I could not claim.* It is as a
lesson rather than as a reproach that I call up the memory of
these irreparable errors and wrongs. No tongue can tell the
heart-breaking calamity they have caused ; they have closed the
eyes just opened upon a new world of love and happiness ; they
have bowed the strength of manhood into the dust ; they have
cast the helplessness of infancy into the stranger's arms, or
bequeathed it, with less cruelty, the death of its dying parent.
There is no tone deep enough for regret, and no voice loud
enough for warning. The woman about to become a mother, or
with her new-born infant upon her bosom, should be the object
of trembling care and sympathy wherever she bears her tender
burden or stretches her aching limbs. The very outcast of the
streets has pity upon her sister in degradation, when the seal of
promised maternity is impressed upon her. The remorseless
vengeance of the law, brought down upon its victim by a
machinery as sure as destiny, is arrested in its fall at a word
which reveals her transient claim for mercy. The solemn prayer
of the liturgy singles out her sorrows from the multiplied trials
of life, to plead for her in the hour of peril. God forbid that
any member of the profession to which she trusts her life, doubly
precious at that eventful period, should hazard it negligently,
unadvisedly, or selfishly ! "

^ Dr. Hlundell and Dr. Rigby, in the works already cited.

PUERPERAL SEPSIS. 66 1

This unanswerable arraignment of the prevailing views in
America in regard to puerperal sepsis, this magnificent appeal
and clarion note of warning, fell upon deaf ears. The very men
who should have first recognized its truth, who should have
most heartily welcomed the revelation, opposed the new doctrine
with all their might, because, forsooth, it ran counter to their
teaching. At that time, in America, two men were so pre-
eminent in obstetrics that they were practically without rivals,
and autocratically dictated their views to a large number of un-
questioning followers. These men were Hodge and Meigs,
holding, respectively, the Chairs of Obstetrics in the University
of Pennsylvania and in the Jefferson Medical College.

Meigs directed against Holmes' teaching all the satire and
ridicule of which his brilliant mind was capable, descending often
to undignified abuse ; Hodge inveighed against it with a pon-
derous invective. But in spite of this powerful opposition the
doctrine of the contagiousness of puerperal fever made rapid
headway, and gained from year to year an increasing number of
converts in America and in England. Hodge's immediate
successor. Dr. Penrose, taught it most impressively.

In 1846 a young assistant in the Maternity Department of
the General Hospital of Vienna, named Semmelweiss, was
struck with the frightful mortality in one of the maternity wards
of the General Hospital, while in a neighboring ward the death-
rate was scarcely one-tenth as great. He discovered that in
the first ward the women were attended by students who were
in the habit of coming fresh from postmortem examinations in
the Pathological Department to the bedsides of the parturient
patients. In the second the women were attended solely by
mid wives. Semmelweiss conceived the idea that the students
carried on their hands putrid products from the postmortem table
to the lying-in women whom they examined, and that these
products were responsible for the large number of fatal inflam-
mations and fevers that followed the students' work. He con-
sequently ordered that no student should examine a w^oman until
he had washed his hands in chlorin-water. The results of his
regulation were fairly startling, as is shown in the accompanying
table :

Confinements. Deaths. Per Cent.

1846, 4010 459 1 1.4

1847, 3490 176 5-

1848, 3556 45 1.27

It should be stated that the rule compelling the students to
wash their hands in an antiseptic solution was put into effect in
the middle of the year 1 847.

662 PA TIIOL OG y OF THE PUERPERIUAf,

Semmelweiss recognized the transcendent importance of his
discovery. He foresaw something of the lives preserved, the
homes kept from bereavement, the mothers saved to their chil-
dren, the wives to their husbands, in millions of families ; the in-
calculable diminution of human suffering which his discovery
promised to the world ; but his was not the calm and confident
soul of a Harvey, wise enough to know that the truth is mighty
and shall prevail : sure that mankind must accept it sorhe day,
and content to bide his time. Semmelweiss* nature was not
great enough for such patience. He fumed and fretted his life
away in vain efforts to obtain recognition for his great princi-
ple of chemical disinfection. He preached his new doctrine in
season and out of season, endeavoring to impress it upon his
immediate colleagues, and upon the medical societies and periodi-
cal medical literature of the time in Europe. During the latter
days of his professorship in Buda-Pesth he would even stop
acquaintances upon the street to importune them with his views.
But he got for his pains nothing but ridicule, contumely, opposi-
tion, or indifference. He finally lost his mind entirely, from chagrin
and disappointment, ending his life in a lunatic asylum in Vienna,
where he died, strangely enough, from a septic wound on his
finger, received during an operation performed just before his
commitment to the asylum.

More than twenty years after Semmelweiss* discovery, the
mortality of many lying-in hospitals in Europe remained as high
as ten per cent. Then came the brilliant work of Pasteur in
the field of bacteriology, the acceptance of the germ theory in
disease, the application of antisepsis to surgery by Lister, and
the adoption of the system almost immediately by obstetricians.
From that day to this there has been a steady and increasingly
rapid acquisition of knowledge of the etiology of septic infection,
and of its most successful preventive and curative treatment.

It is to be hoped that the medical world of to-day and of the
future can never again be deaf and blind to such an appeal as
that of Holmes, or to such a demonstration as that of Semmel-
weiss.

Etiolo£^. — It has become necessary to study the normal
and abnormal microbic flora of the vagina in order to under-
stand fully the etiology of puerperal infection, and to comprehend
the safeguards that nature affords a woman against infection
after labor.

The effective study of the subject dates from Doderlein*s
monograph published in 1892.^ Before this time the presence

' " Das Scheidensekret und sc ne Bedeiitung fur das Puerperal -Fieber," Albert

iJGderlrin, Leipsic, 1S92.

PUERPERAL SEPSIS. 663

of bacilli in vaginal secretions was noted by Hausmann. Conner,
Hunim. Winter, and Steflbck. Conner, in 1887, found in vaginal
secretions many variotits of micro-oi^anisnis, mainly, however,
bacilli, which were extremely difficult to cultivate in the ordinary
culture mL'dia. The cocci in the secretions, many of which
could be cultivated with ease, were found to be non-pathogenic.

Conner concluded that the vaginal secretions contained no
pathogenic bacteria.

Bumm also failed to find pathogenic germs in the vagina.

Winter believed that pathogenic germs were present in the
vagina in a state of lessened or absent virulence.

Doderlein examined the vaginal secretions of 195 pregnant
women. In these examinations notice was taken of the micro-

scopical appearance and of the reaction of the secretions, and
as the result of this preliminary examination the secretions were
declared to be normal or abnormal. In the two conditions the
bacteriological find was quite different. In the normal .secretion,
which was of whitish color, of the consistency of curdled milk un-
mixed with mucus, containing epithelial cells and mucous bodies,
moistened by an exudate from the vaginal mucous membrane
and of an intensely acid reaction, there was found almost exclu-
sively a certain kind of bacillus possessed of distinctive and
characteristic qualities. No pathogenic germ was ever found by
Doderlein in normal vaginal secretions, except a thrush-fungus
which is capable, to a very limited extent, of producing suppura-
tion and destruction of tissue when injected under the skin or

664 PATiWLOGY OF THE PUERPERIUM.

into the eye of an animal. In the pathological abnormal secre-
tion, whicli was yellowish or greenish in color,-of the consisttjncy
of cream, weakly acid or alkaline in reaction, mixed with mucus,
containing often bubbles of gas and secreted usually in very large
quantities, the greatest variety of cocci and bacilli could be found

Of the 19s pregnant women. Doderlein found that 55.3 had
normal and 44.6 had pathological secretions.

Although a number of observers had found bacilli in the
vaginal secretions before Doderlein, no one had so carefully
studied their characteristics, functions, and cultivation ; so that
they are properly called the vaginal bacilli of Doderlein. Tht-j'
are, according to him. anaerobic They have no motion. They
produce by their life-proce.-is an acid medium by forminf,' lactic

acid. They are frequently associated with a yeast -fungu:
(thirty-six per cent, in nonnal secretions only), which Doderleir
believes to be identical with the thrush-fungus, Saccharomycea I
albicans. .

The vagina! bacilli are antagonistic to staphylococci, which J
within certain limits they have the power to destroy. This was 1
shown by several experiments, among others by infecting the \
vagina of a virgin with staphylococcus cultures in large quanti- 1
ties. Within four days the staphylococci had disappeared, and
no bacteria remained within the vagina except tlic vaginal j
bacillus.

Doderlein attributes the germicidal action of the normal J
vaginal secretion to the production of an acid enx^ronmcnt t

PUERPERAL SEPSIS, 665

the vaginal bacillus. He supports this view by the following
facts :

1. That all pathological secretions swarming with sapro-
phytes and with many pathogenic germs are weakly acid or
alkaline.

2. That in a puerpera the vaginal bacillis disappears and in
its place are found many kinds of saprophytes, the lochial
discharge being alkaline.

3. That when the lochia ceases the saprophytes disappear,
the vaginal bacillus reappears, and the vaginal secretion becomes
again intensely acid.

In only 8 out of the 195 cases examined were streptococci
found, and in only 5 of these cases was it possible to demon-
strate by inoculation experiments that the streptococci were
virulent. In 2 cases the streptococcus possessed no virulence
at all.

These discoveries of Doderlein have not been universally
accepted. His views have not gone unchallenged, and further
interesting properties of the vaginal secretions have been pointed
out by others, but we may safely acknowledge Doderlein's
conclusions to be correct in the main, so far as they go, and that
his discoveries constitute the most important advance in the
knowledge of this subject achieved by a single individual.

Following Doderlein's investigation there have appeared a
number of exhaustive studies, the most important conclusions
of which may be briefly summarized as follows :

In series of examinations conducted by Burgubru, Williams,
Stroganoff, and Burkhardt, in 12, 15, 9, and 16 cases respect-
ively, streptococci were found in 1,3, 2, and 5. Or, taking the
sum-total of all these cases with Doderlein's, streptococci were
found twenty-seven times in 542 women examined, showing that
in only a small proportion of cases are dangerous pathogenic
germs to be found in the vaginal secretions of pregnant women ;
and accepting Doderlein's results as correct along with those
of Winter, even of this small proportion of cases in jvhich strep-
tococci were found, a considerable proportion of the streptococci
were non-virulcnt.

Kronig, ^ in about 200 examinations, found that the vagina in
pregnant women, aside from the gonococcus and the thrush-
fungus, contained no pathogenic micro-organisms. The strepto-
coccus was not found in a single case. Adding these examina-
tions to the former series, the proportion of cases in which the
streptococcus may be found is, as appears, still further reduced.

^ " Deutsche med. Wochenschr.," 1894, Oct. 24, p. 819. ^

666 PA THOL OG Y OF THE PUERPERIUM.

Moreover, Kronig found, after inoculating the vagina with pure
cultures of streptococcus, staphylococcus, and bacillus pyocy-
aneus, that none of these micro-organisms could be discovered
after eleven to twenty hours.

Kronig attributes the germicidal properties of the vagina, which
are demonstrated by these observations, mainly to the flow out-
ward of the vaginal secretions, and not to any special microbe
having its normal habitat in the vagina. According to this
observer, acid, neutral, and alkaline secretions all have germi-
cidal power. Further, Kronig found that if an hour after the
infection of the vagina an antiseptic douche of lysol were admin-
istered, not only were the infecting micro-organisms not de-
stroyed by the douche, but also that it took the vaginal secretions
from nineteen to thirty-six hours to destroy microbes that u-ith-
out the douche would disappear in from eleven to twenty hours.

These results were confirmed by Menge,^ in a study of the
germicidal power of vaginal secretions in non-pregnant women,
except that Menge occasionally did find streptococci in the
vagina. From a number of observations and experiments this
observer forms the following conclusions as to the causes of the
germicidal power of vaginal secretions, putting them down in
the order, as he believes, of their importance :

The antagonism of the normal microbic flora of the vagina
and of the pathogenic micro-organisms which may be deposited
there by accident.

The products of the life-process of the vaginal bacilli.

The acidity of the secretions.

The germicidal powers of the anatomical elements of the
vagina.

The leukocytosis which is provoked by chemotaxic action
either of the vaginal discharges or of the infecting micro-organ-
ism invading the vagina.

The phagocytosis following leukocytosis.

The absence of free oxygen in the vagina.

Walthard ^ has recently contributed valuable information
from the bacteriological study of the vagina in lOO women a9ite
ct post partuin.

According to Walthard, the genital canal of women is di-
vided practically into two parts— one infected, the other sterile.
The former comprises the vestibule, the vagina, and lower por-
tion of the ccr\'ical canal. The latter, the upper portion of the
cervical canal, the uterine cavity, and the tubal canals. The

^ " I)outscbe med. Wochenschr.," 1894, Oct. 24, p. 819.
, '^ " Archiv f. Gyn.," vol. xlviii, p. 20I.

PUERPERAL SEPSIS. 667

causes of this division of the canals, according to Walthard,
are :

1. The plug of mucus stopping up the cervical canal, which,
though not in itself germicidal, is deficient in albuminoids and fur-
nishes no nutriment for micro-organisms.

2. The leukocytes, which are found in great numbers where
the cervical secretion mixes with the vaginal secretion at the
level of the external os.

According to this observer, there are really three divisions
of the genital canal : one, the lower, containing leukocytes and
bacteria ; the next, containing only leukocytes, and the third, the
upper, containing neither leukocytes nor bacteria.

It is supposed that the outpour of leukocytes is due to a
chemotaxic action excited by the mixture of cervical and vaginal
discharges, and that the phagocytosis follows naturally the leu-
kocytosis.

In the vaginal discharges Walthard found, both during preg-
nancy and after delivery, pathogenic microbes, streptococci,
staphylococci, gonococci, and the colon bacilli. The first
named were found in 27 out of the 100 women examined,
but these streptococci had lost all virulence and had become
veritable saprophytes. Inoculation experiments with them pro-
duced no results — that is, if they were inserted in normal tissues ;
but if a certain region of the animal's body was reduced in
vitality, or if the condition of the animal's system was lowered
in any way, the inoculation of these streptococci produced
abscesses in which the micro-organisms rapidly regained all
their original virulence until they became quite as deadly as the
most dangerous of their kind. From his experiments and ob-
servations, Walthard draws the following conclusions :

The virulence of vaginal streptococci of a pregnant woman
not examined for some time is equal to that of the streptococci
that live upon other mucous membranes or in their secretions.
In other words, the vaginal streptococci are not virulent, and
behave as saprophytes upon healthy tissues ; but as in the case
of the intestinal streptococci, the vaginal streptococci can become
infectious when the resistance of the tissues with which they are
in contact is diminished. The virulence that the vaginal strep-
tococci attain under these circumstances is quite equal to that of
the streptococci of puerperal infection.

Stroganoff, ^ from an examination of eleven pregnant women,
supports Doderlein's assertion that the vaginal bacillus pro-
duces by its development lactic acid, and shows that, while

^ * Monats. f. Geb. u. Gyn.,*' Bd. ii, p. 381.

668 PATHOLOGY OF THE PUERPERIUM.

the vaginal secretions of the new-bom are very weakly acid,
they become more and more acid as bacteria develop in the
vagina. He quotes experiments of Schlatter, showing that an
acid medium retards the growth of the staphylococcus and is
destructive to the streptococcus of erysipelas. He further shows,
by experiments with culture media, that the vaginal bacillus pro-
duces not only an acid medium, but also other products of its
life-processes that retard or prevent the growth of the staphylo-
cocci.

In these experiments the vaginal bacillus was cultivated, and
the culture then raised to a high temperature, so that the bacilli
were destroyed. The culture was then inoculated with the
staphylococcus pyogenes albus, with negative result. If the
culture, in addition to being treated as described, was made alka-
line, the staphylococci grew, but not so vigorously as upon the
same culture medium in which the vaginal bacillus had not been
grown.

Stroganoff explains the sterility of the upper cervical canal
and of the uterine cavity by the active germicidal properties of
the cervical mucus, by the mechanical action of the flow of men-
strual blood, by the same action of the descending placenta and
membranes, and by that of the lochial discharge. Perhaps there
should be added the germicidal effect of blood itself, which
property it has been recently demonstrated that blood possesses,
to a certain extent.

Stroganoff announces the following conclusions from his
study : One finds in the vagina of pregnant women always a
quantity of micro-organisms. The prominent form in normal
cases is the bacillus, but there are, in addition, usually other forms
present. Micro-organisms which liquefy gelatin are met with
comparatively seldom in normal cases, and then only in small
numbers. A pathological condition of the vaginal mucous mem-
brane alters the normal flora. The vaginal secretion of pregnant
women is strongly acid in reaction. In addition to micro-
organisms, one sees usually under the microscope epithelial cells
and isolated white blood-corpusclcs. The cervix contains nor-
mally no micro-organisms. When these are present in that
situation, their number is small. The reaction of the cer\'ical
secretion is alkaline. In not a single case were there organisms
in the cervix which liquefied gelatin. The external os is usually
the boundary between that portion of the genital canal which
contains micro-organisms and that portion which does not.

Viable ^ finds that for the first twenty-four hours the vaginal

^ " Zeitschr. f. Gcb, u. Gyn.," Bd. xxxii, H. 3, v.

PUERPERAL SEPSIS. 669

secretions of new-bom infants are sterile. By the third day
they always contain micro-organisms, and in a considerable pro-
portion of cases the staphylococci pyogenes albus and aureus
and a streptococcus.

Stroganoff finds that within a few hours of birth the vagina
becomes infected, and that in a certain proportion of cases the
inoculation occurs />/ utcro^ or during the passage of the child's
body through the vagina. This is most likely to occur in breech
presentations. A great variety of micro-organisms may be found
in the vagina of the newly bom, including streptococci, diplo-
cocci, staphylococci, etc. •

From this mass of facts, set down without any special order,
confusing in its complexity and occasionally in its apparent
contradictions, the practical physician may draw the following
conclusions as to the etiology of puerperal sepsis : The vagina
becomes infected almost immediately after birth. In a normal
condition it contains no pathogenic bacteria. It has strong
germicidal powers which serve to guard a woman against infec-
tion. These powers depend upon the presence of a special
bacillus, and upon the products of its life-processes ; upon the
leukocytosis due to chemotaxic action ; upon phagocytosis ;
upon the germicidal powers, perhaps, of the anatomical elements
of the vagina ; of the cervical mucus, and of the bloody dis-
charge during menstruation and the puerperium.

During and after labor, mechanical safeguards of the most
effective kind are fumished against infection. These are : the
discharge of the liquor amnii, washing the vagina out ; the
passage of the child's body, scrubbing the vagina out ; the
descent of the placenta and membranes, and the bloody dis-
charge which follows.

Moreover, should the vagina contain pathogenic bacteria,
they are likely to be in a condition of diminished or absent viru-
lence, in which they will not be productive of disease.

Bearing these facts in mind, it is apparent that the common
practice of relying upon simple vaginal douching for disinfecting
the vagina before labor, or before some gynecological manoeuver
or operation, is faulty, not to say foolish. It has been clearly
demonstrated that the injection of an antiseptic fluid into the
vagina will not destroy pathogenic germs there, and will rob the
woman, to a certain extent, of the safeguards that nature pro-
vides for her against infection. If, therefore, under certain cir-
cumstances, it is desirable to disinfect the vagina, mere douching
should not be depended upon, but the vaginal mucous membrane
should be thoroughly scrubbed out as well as douched, just as
one would prepare the skin for an important surgical operation.

670 PATHOLOGY OF THE PUERPERIUM.

It is clear that these remarkable discoveries in regard to the
micro-organisms normally present in the vagina do not, in the
slightest degree, lessen the importance of antiseptic precautions
on the part of medical or other attendants upon a patient in
labor. The presence of these organisms in the vagina might
possibly be used as an argument against the necessity for anti-
septic precautions. For, it might be said, the vagina being
already infected, it is unnecessary to observe such elaborate pre-
cautions against infecting it still more.

But when one considers that the micro-organisms in the
lower genital canal arc -not infectious at all in the vast majority
of cases, and that when they arc their virulence is diminished or
absent, it is obviously incumbent upon any conscientious man
not to insert into the vagina infecting bacteria which may, by
their number and virulence, overcome all the safeguards that
nature provides, and may, consequently, be the cause of a serious
and fatal disease.

The Pathogenic Microbes Capable of Producing: Local In-
flammation and General Systemic Infection when Introduced
in the Genital Canal. — Doderlein found, in five cases of serious
puerperal infection, the streptococcus pyogenes as the sole infect-
ing agent.

Czerniewski, in 53 cases of puerperal infection, found strepto-
cocci in 49. In a histological and bacteriological examination
of 16 cases of puerperal fev^er, Widal found streptococci in 14,
bacilli in 2. Bumm, in an examination of 17 cases of puerperal
infection, found streptococci in all — 5 times as pure cultures, i 2
times mingled with small numbers of staphylococci and of other
germs. Thus, in a total of 91 cases, the streptococcus was
found to be the infecting agent in 85, or 94 per cent.

Following streptococci, but a long way behind as the cause
of puerperal infection, are the pyogenic staphylococci, the colon
bacillus, the gonococcus, the bacillus pyocyaneus, the bacillus
fcetidus, the pneumococcus, the Klcbs-Loffler bacillus of diph-
theria, the tetanus bacillus, and possibly any germ at all that,
inserted into living tissues or deposited upon weakly resisting
surfaces, is capable of causing local inflammation or general
disease. In addition to specific .septic micro-organisms, the
saprophytes of decomposition play an important role in the
common form of puerperal sepsis, due to the absorption of
toxins, or ptomains produced in the decomposition of dead
animal matter, such as blood-clots, fragments of placenta, hyper-
trophicd dccidua, within the womb. Dobbin^ has reported an

^ " PutTjHnal Sepsis due to Infection with tlie Bacillus Aerogenes Capsulalus,**
**Joiins Hopkins. Hospital bulletin," No. 71, February, 1S97.

PUERPERAL SEPSIS, 67 1

interesting case of fatal puerperal infection, in which the bacillus
aerogenes capsulatus (gas bacillus) was probably the infecting
agent, or, at least, produced the toxins that fatally intoxicated
the maternal organism, and, after death, developed the same
emphysema in the maternal body which was found in the dead
and macerated fetus at the time of delivery. This is the germ
which is accountable for cases of physometra, or tympanites
uteri. It develops by preference in dead bodies, and may not
manifest its presence during life. It finds in the dead fetus
within the womb a habitat most suitable for its development ; it
gives rise to a horribly fetid gas, and probably to virulent toxins.

J. VVhitridge Williams, of Baltimore, in an examination of
forty patients, the cultures being taken from the ward cases
whenever the temperature went to or above 101° F. and from
the out-door cases when it reached 102°, found —

Streptococci in 8 cases

Staphylococci in 2 cases

Colon bacilli in 6 cases

Strictly anaerobic bacteria in 4 cases

Unidentitied aerobic bacteria in 5 cases

Bacteria were found in cover-glass examinations, all cul-
tures being sterile, in 4 cases

Diphtheria bacilli in I case

Bacillus aerogenes capsulatus in I case

Typhoid bacilli in i case

Malarial plasmodia in blood, cultures sterile, in . . . I case
No bacteria on cover-glass, cultures sterile and blood

negative, in II cases

making a total of 44 cases, the difference between that num-
ber and the 40 cases actually examined being due to the fact
that there were mixed infections in several instances.

The Manner in which Pathogenic Org^anisms Find an
Entrance into the Genital Canal. — The majority of puerperal
infections are traceable to the insertion of pathogenic germs by
the examining finger or hand of the physician, who in the course
of his daily work may have touched the dried sputum of diph-
theria, the desquamated skin of scarlet fever, suppurating wounds,
erysipelatous surfaces, and other virulent, infectious material ;
so that at any time his hands may fairly reck with the most
dangerous poisons that could possibly be brought in contact
with the parturient and puerperal woman. Many hundred cases
have been traced directly to the association of the physician with
infectious diseases, and there is scarcely a surer way of avoiding
puerperal infection than by abstention from vaginal examinations.
Epidemics of puerperal fever in hospitals have been quickly
stamped out by avoiding all internal examinations, and the best
morbidity and mortality records ever known have been obtained

6/2 PATHOLOGY OF THE PL'ERPERIUM.

recently in institutions in which vaginal examinations were
eliminated as much as possible. The hands of the nurse or
other attendants may be the agents that dep>osit bacteria in the
vagina or upon the vulvar orifice. The impleinents used in and
about the parturient canal, an atmosphere laden ^ith dust or
vitiated by foul hygienic conditions, and the water used to wash
and douche the patient may carry disease germs to the par-
turient woman and may introduce them into the genital canal
The bed-clothing, the personal clothing, the mattress, the
vulvar pads, the material used to cleanse the vulva (rags,
sponges, cotton, cloths), may each and all be sources of infec-
tion.

Putrescible material retained within the genital canal (espe-
cially within the uterine cavity) attracts the innumerable and
ubiquitous saprophytes and their spores, with which the purest
atmosphere swarms. The development of these bodies in a
situation most favorable to their growth and active propagation
may easily result in a toxemia, if not \i\ actual invasion of the
body by pathogenic germs.

r'inally, a certain proportion of cases may be traced to auto-
infection — that is, to pathogenic germs resident \x\ the body, and
not introduced from without during or after labor. These germs
UKU' have had a lodgment in the vagina, as has been demon-
strated in the bacteriological studies of that canal recently made :
or they may have been contained in a limited area near the
genital canal, as in an old pyosalpinx. whence they spread b>'
rupture of the pus-sac during labor, or in w^hich thev are incited
to now activit)' by the compression and consequent reduction of
vitaiit)' of surrounding tissue. Or there may be, in the neigh-
borhood o{ the uterus, tumors of low^ vitality and highly
putrescible material, which, being reduced \n resisting power b>*
comi)rcssion from the descending child, become infected b)'
germs that ordinarily can not influence vigorous bodv-cells.
Urrmoiil c\sts and fibroid tumors are the best examples of these
''i-inNlhs.

It is claimed that even highly vitilized tissues like the pehic
muscles. csjHcially the iliopsoas, may be so bruised and in-
jured by the child's head that they slough and become gangre-
nous. I he iliac bcMie, too, has become carious after the bruisin*^
ti^ which it was subjected in a prolonged forceps o{>eration.

The parturient wiMiian may have been, before conception, the
subject (M" an interstitial endometritis, caused by the presence in
the cndi>mctrium *>!* some pathogenic germ. This germ bdng
Iodised in the inicr>tices of the uterine mucous membrane, and
the wv>man bccomini; pregnant, there is contained m the uterine

PUERPERAL SEPSIS, 673

cavity, even before labor, an efficient cause, perhaps, of virulent
puerperal sepsis after delivery.

Cases in which infection followed child-birth in this way have
been recently reported by Gottschalk and Immerwahr. ^

The Behavior of Pathog^enic Micro-organisms when Intro-
duced into the Genital Canal or Deposited upon Its Entrance.
— The consequences of microbic invasion of the genital canal by
pyogenic germs are variable in the extreme. If the bacteria enter
wounds in or near the vaginal outlet, the result may be the same
as in the infection of any wound in general surgery — that is to
say, local inflammation, suppuration, and perhaps general sys-
temic infection ; but the infectious inflammation of a vaginal
wound is almost certain to spread upward, for the conditions are
more favorable to microbic growth and to systemic invasion in
the uterine cavity and in the tubal canals than in the lower
portion of the genital tract Hence it is that the vast majority
of serious puerperal infections have their effective starting-point
within the womb. For example, it has been found, in a strepto-
coccic infection of the whole genital tract, that the micro-
organisms were present in the vaginal mucous membrane alone,
in the cervical mucous membrane, and in the tissues immedi-
ately subjacent ; in the endometrium, and deep within the uterine
muscle, showing that they could easily penetrate the deeper
tissues within the womb, while they were incapable of invading
the tissues underlying the vaginal mucous membrane. In other
words, the resisting power of the tissues under the mucous mem-
brane is less the higher the micro-organisms are found in the
genital canal. ^

Septic infection of the genital tract results often in the forma-
tion of false membranes. This is true of pure streptococcic
infections, of mixed infections (streptococcus, bacillus foetidus,
bacillus pyocyaneus, the pyogenic staphylococci), and especially
true, of course, of the rare cases of true diphtheria of the
genital tract in which the Klebs-Loffler bacillus is found.

The apparent false membrane in a septic endometritis is
due to a necrosis of the endometrium, clothing the uterine walls
with a dirty, greenish-yellow covering. There is much yet to
learn of the antagonisms and associations of pathogenic germs
in puerperal infections. This much, however, may be asserted
with confidence : the streptococcus is frequently associated with
the pyogenic staphylococci, the bacillus ftetidus, the bacillus
pyocyaneus, and the colon bacillus, though it is said to drive

1 *• Ueber die im weiblichen Genitalcanale vorkommenden Bakterien in ihrer
Beziehnng zur Endometritis,** ** Archiv f. Gyn.," Bd. 1, H. 3.

' Lahn, ** Inaug.-Diss. " Jarhresbericht, 1894.
43

674 ^^ THOL OG V OF THE PUERPERIUM,

away or to destroy the staphylococci after a time. These mixed
infections are, in my experience, the most fatal.

The gonococcus seems often to prepare the way for the strep-
tococcus, which, in its turn, may destroy the gonococcus, con-
quering the latter in a struggle for existence and remaining in
sole possession of the field. The streptococcus appears often to
prepare the way for the colon bacillus, which certainly wanders
in frequently in the course of streptococcic infection.

Streptococci, staphylococci, and the pyogenic bacilli have
preeminently the power to penetrate the tissues of the uterus
and to distribute themselves throughout the body. This is
particularly true of the streptococci.

Gonococci and the colon bacilli confine themselves most
often to the endometrium. The former is the pathogenic agent in
a large proportion of the cases of septic endometritis after labor.
Both of these organisms, however, can penetrate the uterine
muscle, and may be distributed by the lymph-channels or by the
blood-vessels throughout the system. The putrefactive micro-
organisms (saprophytes) are themselves anaerobic, and confine
their activity mainly to the decomposition of the endometrium
and of putrescible uterine contents, particularly a hypertrophied
endometrium, which is practically cut off from its blood-supply
by the contraction of the womb, and which is peculiarly liable
to rapid decomposition. During the process of the putrefaction
the saprophytes manufacture soluble and absorbable products
(toxins) of a highly pathogenic nature, causing in many a
case a fatal intoxication without actual microbic invasion of the
body. Moreover, these same saprophytes occasionally attack
blood-clots in the uterine sinuses, and may in them, by detach-
ment of a thrombus, be swept into the general circulation and
deposited as a septic embolus in different portions of the body,
causing metastatic abscesses.

Symptoms and Diagnosis of Puerperal Infection. — The
symptoms of puerperal infection are local and general. The
latter are : an elevated temperature, preceded perhaps by a chill ;
a rapid pulse, and profound physical depression, with the devel-
opment in some cases of metastatic inflammations of any of the
organs or tissues in the body. The tongue is coated ; the breath
is heavy. There is a disinclination to take food. There may be
intense thirst ; nausea and vomiting are not uncommon, and a
septic diarrhea appears in the worst cases. There may be
blotches of a scarlatiniform eruption upon the skin.

The local symptoms of septic infection are : a foul discharge,
redness of the mucous membrane, spots of ulceration and false
membrane formation along the lower genital canal, edema of the

PUERPERAL SEPSIS. 675

vulva, and, possibly, pelvic peritonitis with an exudate. Or there
may be other inflammatory affections of the generative organs,
such as superficial catarrhal colpitis or ulcerative metritis, the
symptoms of which are described in their appropriate places*
It is not likely that any case of puerperal sepsis will present all
the symptoms just detailed. Elevation of temperature and rapid
pulse alone after labor should be regarded as indicative of puer-
peral infection if no other cause for them can be demonstrated.

It is possible, indeed, to see elevation of temperature alone as
a symptom of puerperal infection in the early part of the puer-
perium, during which time the influences that normally reduce
the pulse-rate are so active as to counteract the disposition to
rapidity of pulse usually shown in septic infection. The slow
pulse, however, does not continue long. At the end, usually, of
thirty-six hours, rapid heart-action appears.

It may be impossible to make a differential diagnosis between
septic fever and some of the other causes of elevated temperature
after labor. In these cases it is wise to treat the patient for
puerperal sepsis by a thorough disinfection of the parturient tract,
while at the same time the bowels are well evacuated and a full
dose of quinin is administered to dispose of a possible intestinal
toxemia, and to combat a possible malarial infection which in
many parts of the country, especially in the spring and fall, is a not
improbable event. A microscopic examination of the blood is
advisable in a doubtful case, to discover the leukocytosis of sepsis
or the protozoa of malaria.

Any elevation of temperature after delivery calls for the most
careful investigation. A vaginal examination should be made,
both digitally and with the speculum, to detect the following con-
ditions : Redness of the mucous membrane and edema of the
vulva ; false membranes and ulceration in the vagina ; arrested
involution and fixation of the uterus ; bogginess and extreme
tenderness of the uterine walls ; enlargement of the tubes ; en-
largement, fixation, or displacement of the ovaries ; edema or
exudate in the pelvic connective tissue, and thromboses in the
pelvic veins. The abdomen should be carefully palpated for
tenderness and exudate ; the character and odor of the lochia
must be observed. In short, the woman's condition should be
thoroughly studied to eliminate or to discover some other cause
for fever than an infection of the birth-canal.

Preventive Treatment of Puerperal Sepsis. — It is conveni-
ent to deal separately with the several sources of puerperal
infection in describing the preventive treatment.

Atmosphere. — While the air is not so frequent a source of
infection as it was thought to be in the beginning of the antir

676 PATHOLOGY OF THE PUERPERIUM,

septic era, it is undeniable that an atmosphere which is stag-
nant, deprived of sunlight, impregnated with dust, tainted with
foul odors and mephitic gases, may not only contain disease
germs and spores in larger proportion than it should, but also
has a most depressing effect upon an individual subjected to its
influences, reducing the vitality and resisting power of that indi-
vidual until there occurs, perhaps, microbic invasion of the
system that would have been successfully resisted had the body-
cells preserved their normal combative power against patho-
genic bacteria. The lying-in room, therefore, should be sunny ;
should be well ventilated — ^best by an open fire-place ; and it
should not possess a stationary wash-stand or any other connec-
tion with the sewer ; nor should it be too near the bath-room
and water-closet. If there is a stationary wash-stand in the room,
its outlet should be kept stopped, water should be allowed to
stand in it, and the overflow holes should be plugged with small
corks or putty. If the bath-room immediately adjoins the
lying-in room, the door between should be stripped.

If the room is heated by a hot-air furnace, the intake for the
air and the sanitary condition of the cellar may need investiga-
tion. The nurse should be cautioned not to leave trays of food,
an unempticd bed-pan, or a commode in the room over night or
for any length of time. An antiseptic vulvar pad should be
worn during the continuance of the lochial discharge, so as to
protect the genital orifice from contact with the atmosphere, and
the materials of which this pad is composed, or, rather, the anti-
septics with which it is impregnated, should be chosen with a
view of keeping the bloody discharge from decomposing, should
it soak through the pad, and thus be exposed to atmospheric
contamination. The best materials for this purpose, in my ex-
perience, arc salicylated cotton and carbolized gauze.

Water. — The water used for douches, if they are employed,
or for washing the vulva and perin%im, may be the source
of fatal infection. All the water used about the puerpera should
be boiled beforehand for at least half an hour. It is not suffi-
cient to make a germicidic solution — as, for example, of corrosive
sublimate — in the belief that all germs in the water are killed by
the antiseptic employed. Tetanus bacilli will live for hours in a
I : 4000 bichlorid of mercury solution, and the other antiseptics
usually employed in obstetric practice — lysol, kresin, creolin —
may be perfectly inert against many dangerous pathogenic germs
during the time that usually intervenes between the preparation
of an antiseptic solution and its use upon a patient. I have seen
three women contract tetanus from intra-uterine douches of
unboiled water (creolin. two per cent.), during a time when the

PUERPERAL SEPSIS, 677

water of Philadelphia was unusually turbid, in consequence of
freshets in the Schuylkill Valley.

The Patient. — The parturient and puerperal woman may be
infected by disease germs carried upon her person, especially in
the pubic and anal regions ; by her personal clothing, by the
bed-clothing and mattress, by the vulvar pads and the pads upon
which the buttocks rest, by the material used to wash the vulva
and perineum, and by pathogenic bacteria lodged in the vaginal
or uterine mucous membranes before labor or even prior to con-
ception.

To insure the greatest obtainable degree of personal cleanli-
ness, the woman falling in labor should be given a full bath,
special attention being paid to scrubbing the genital region most
thoroughly with soap, hot water, and a soft, bristle brush or a
wash-rag. After the bath, the woman should put on clean
clothes throughout. The mattress on her bed should not be
soiled by the discharges of previous labors, by urine, feces, or
other putrescible matter. It should not have been used in any
case of contagious or infectious disease, and it should be pro-
tected by a rubber cloth that has been carefully scrubbed clean.
The bed-clothing should be clean, the bed being freshly made
up for the labor. The pads on which the buttocks rest during
labor and afterward should be made of nursery cloth prepared in
the way described in the directions to the nurse (boiled and
dried). It is scarcely necessary to say that a pad when soiled
should be thrown away and not used again. The vulvar pads
should be made of carbolized gauze and salicylated cotton — ^the
best materials for disinfecting a bloody discharge. The nurse
should make them up with sterile hands as they are required, or
if she makes a number at a time they should be wrapped in a
clean towel and taken out for use with sterile hands. The
material used to wipe off the genital orifice, the mouth of the
urethra, and the perineum should be absorbent cotton soaked in
a I : 1000 solution of sublimate for at least a half hour before
its use. During the second stage of labor these pledgets of
cotton are employed to wipe away feces as it emeiges from the
anus, always in the direction from before backward.

Care must be exercised to remove blood and blood-clots
from the vulva before putrefaction sets in. This is best done by
placing the woman on a bed-pan, letting a stream of boiled
water run over the parts, and, if necessary, using cotton to wipe
them off. This should be done about six times in the twenty-
four hours for the first four or five days.

A careful examination should be made of every woman's
vaginal discharges in the beginning of labor. If there is leukor-

678 PATHOLOGY OF THE PUERPERIUM.

rhea, or any pathological condition of the vaginal secretions, the
vagina should be thoroughly scrubbed with tincture of green
soap, hot water, and pledgets of cotton, and should then be
douched with a bichlorid of mercury solution, i : 2000, a little
clear water being employed at the end of the douche to wash
out any residual sublimate solution that might poison the
patient or do harm to the infant's eyes in its descent through the
birth-canal.

It should be borne in mind, in the conduct of the labor, that
excessive bruising, long-continued pressure of the maternal
tissues, extensive injuries, all conduce to microbic invasion of the
parts by reducing their vitality and by affording, through solu-
tions of continuity, a ready entrance into the system. The proper
conduct of labor, therefore, is an extremely important item in the
preventive treatment of puerperal sepsis.

Finally, in the management of the third stage of labor and
of the early puerperium, the greatest care should be exercised to
evacuate the uterine cavity of all putrescible matter and to secure,
so far as possible, firm contraction of the womb, for the presence
of dead foreign matter within the uterine cavity will almost surely
attract saprophytes, and an imperfect involution of the womb
will favor the direct invasion of the uterine sinuses and blood-
channels by micro-organisms and the absorption of the products
of microbic activity into the circulation and into the lymph-
spaces.

The Physician. — The physician should not carrj^- infectious
germs upon his person or clothing into the lying-in chamber,
and he should be scrupulously careful not to insert pathogenic
germs into the woman's vagina in the course of his examinations.
If a general practitioner is in attendance upon infectious and
contagious diseases, he should either give up obstetric practice
entirely, or, if he can not do so, he should take a full bath and
should change his clothing completely before attending a woman
in labor.

It is a wise precaution to carr}^ in one's obstetric bag a long
linen gown or a pair of duck trousers and a cheviot shirt. The
change of clothing should be made in another room before seeing
the patient at all, or, at any rate, before making an examination.

In the preparation of his hands for an examination the method
recommended by T^irbringer is to be preferred. This consists
of a ten minutes' scrubbing of the hands with a nail-brush, hot
water, and tincture of green soap, either with running water or
with at least four changes of water in a basin. The water
should be boiled and filtered. The preliminar)' scrub is
followed by a two minutes' scrubbing with alcohol, using a
fresh nail-brush, and this is followed by immersion of the

PUERPERAL SEPSIS, 679

hands in a i : 1000 bichlorid of mercury solution for at least
two minutes. ^ The examining finger should then be anointed
with carbolized vaselin (five per cent.), and in making the ex-
amination the vulvar orifice should be exposed by lifting up the
upper buttock as the woman lies upon her side, so that the finger
may be inserted directly into the vagina without becoming con-
taminated by being swept over the skin near the anus or pubes
while searching for the vulvar orifice. As every examination
entails upon the woman some risk of infection, the examinations
should be limited in number as much as possible. The best
results ever obtained in obstetrical practice, as regards both mor-
bidity and mortality, have been secured by an almost entire
elimination of the vaginal examination, which has been replaced,
in the practice of some enthusiasts, by abdominal palpation, and
even by rectal examinations. It is unnecessary, however, and
is, moreover, inadvisable to give up the vaginal examination
altogether. Much may be learned by abdominal palpation, so
that there is little necessary information to be gained by
examining per vaginam, but there are conditions that can be
learned in no other way. A few vaginal examinations in the
course of labor are therefore indispensable. No harm is done by
these examinations if their number is restricted and sufficient care
is exercised to secure perfect cleanliness of the examihing hand
and to conduct the examination in the way just described.

The Nurse. — The nurse should adopt the same precautions
in regard to personal cleanliness that have been recommended
for the physician. She should not have come from a contagious
or infectious case. She should put on fresh clothing throughout
for attendance upon the obstetrical patient. She must take a
full bath, scrubbing her hair and scalp well with soap and water,
and rinsing her hair in a i : 1000 sublimate solution. Her
hands should be carefully prepared according to the method pre-
viously described before any manipulation of a patient's genital
region or of her breasts. It is her duty also, in the care of a
puerpera, to enforce the sanitary and aseptic regulations already
described under their appropriate heads.

The Implements. — AH implements to be used about the person
of the parturient and puerperal woman should be boiled for at
least five minutes. In the case of a few articles that might be
injured by boiling water a bichlorid solution i : 1000 should be
employed for their disinfection, a full half hour at least being

* If the hands have been badly infected with a particularly virulent micro-
organism, as in an operation for septic perifonUis^ ihere is no method that makes them
aseptic. They remain infected for at least three days, even with a daily disinfection.
Rubber gloves should be used in all very infectious operations ; or, if the hands
Ijccome infected, rubber gloves should be worn in all obstetrical and surgical work
for the next three days.

680

PATHOLOGY OF THE PUERPERIUM.

allowed for the immersion, and the bichlorid solution being
made up with boiled water.

The Curative Treatment of Puerperal Infection. — The treat-
ment of puerperal sepsis is both local and general. Locally, a
thorough disinfection of the whole genital canal is called for in
every case of puerperal infection. It may appear unnecessary,
and may prove, on actual experience, to be even harmful, but no
one can tell beforehand how necessary this procedure will be.
In the vast majority of cases it will be productive of the greatest
good. It is only occasionally useless, and very rarely actually
harmful. It should, as already stated, invariably precede all
other treatment for puerperal infection. The method of dis-
infecting the genital canal may be described as follows : A
double tenaculum, a large, dull curet, a placental forceps, and
an intra-uterine catheter are boiled for fifteen minutes. The
operator disinfects his hands and arms. The patient is placed
in the dorsal posture across the bed, with her buttocks resting

Fig. 488.— Tempei

on a rubber pad. The external genitalia and the vagina are
scrubbed with tincture of green soap and pledgets of cotton ;
the vagina is douched with a sublimate solution, i : 2000. The
operator then seizes the anterior lip of the cervix with the tenac-
ulum. An intra-uterine douche, sublimate solution 1 : 2000, at Ica.st
a quart, is administered. Then with the curet and the placental
forceps in turn the uterine waits are gone over thoroughly in all
directions, six to twelve times, until nothing is brought away but
bright blood. A .second intra-uterine douche concludes the
treatment. If the womb is flabby and large, with a tendency
to flexion, so that the drainage of the uterine cavity is not good,
it is advisable to pack the cavity with iodoform gauze.

PUERPERAL SEPSIS, 68 1

In addition to cleansing the uterine cavity in the manner
described, the operator should take the opportunity of carefully
inspecting the visible portion of the parturient tract ; and if
there are false membranes or areas of inflammation and localized
infection on the cervix or in the vagina, they should be carefully
treated — best by the application of a strong solution of nitrate
of silver, a dram to the ounce.

It may be necessary to repeat the intra-uterine douches several
times — in fact, several times a day for many days ; in this case
plain water only should be used. Nothing is gained whatever
by the employment of strong chemical disinfectants, which can
not always reach and destroy the infecting micro-organisms of
the genital tract, but which do have a most depressing action
upon the body-cells of the walls of that tract, reducing their
resisting power against the invasion of attacking bacteria.

It is rarely necessary to repeat the curetment or the use of
the placental forceps. It may be advisable to provide drainage
from the uterine cavity by the insertion of a strip of gauze to
the fundus. This is only necessary, however, in those cases of
flabby, relaxed wombs which fall forward on themselves in such
a manner as to prevent the free exit of the lochial discharge.

The general treatment is stimulating. The patient should
have as much food of an easily digestible character, chiefly milk,
as she can assimilate, and as much alcohol as she can consume
without showing the physiological effects of it. Digitalis is
useful as long as the pulse is above no. Strychnin may be
combined with it in suitable cases. To tide the patient over
emergencies, carbonate of ammonia in large doses, by the bowel,
and nitroglycerin hypodermatically, may be required. Inhala-
tions of oxygen may also be of service. Absolute rest and
freedom from all disturbances, mental and physical, must be
insisted upon, and the patient should be given the best nursing
that the family can afford.

The Serum-therapy of Puerperal Sepsis. — Stimulated by the
success of this treatment in diphtheria and in a few other infec-
tious diseases, an effort has been made to procure a serum that
is antagonistic to streptococci and antidotal to the products of
their activity.

Richet and Hericourt ^ suggested, some years ago, the use
of serum taken from animals " vaccinated " with a septic micro-
organism, in order to secure immunity in other animals. Many
enthusiastic investigators have recently worked in the same
field, especially in France ; but Marmorek's work has com-

1 (<

Comptes rendus de 1' Academic des Sciences," 1 888, p. 690.

682 PA THOLOG V OF THE PUERPERIUM.

manded more respect and attention than that of any other single
worker ; and it will not be unfair, therefore, to judge the merits
of serum-therapy of puerperal sepsis by the results achieved
with Marmorek's products.^

There are two ways of immunizing animals. One is to take
culture media with the microbes destroyed or removed, and
containing only the toxins of streptococcic activity. The other
is to inject the streptococci themselves into the animal which is
to be made immune. The latter is much the more reliable
method.

Marmorek was able to immunize horses, asses, sheep, and
mules by injecting exceedingly virulent streptococcic cultures in
increasing doses during a period of six to ten months. Taking
the serum from the animals at least four weeks after the subsi-
dence of all the symptoms in the reaction following the last
inoculation, he found that T^inr P^^ ^^ ^ guinea-pig's weight
in serum was sufficient to protect it against ten times the dose
of virulent streptococci, which would be fatal in animals
unprotected.

But he admits that there may be a streptococcic infection so
virulent that no antidote is of avail, and also that if the anti-
streptococcic serum is employed late after the primary infection,
the progress of the septic inflammation can not be arrested.

Moreover, the antistreptococcic serum has no antagonistic
power over the other micro-organisms of puerperal sepsis ; so
that the quite common cases of mixed infection in which the
colon bacillus, the bacillus foetidus, the bacillus pyocyaneus, and
the pyogenic staphylococci are active may not be benefited in
the least by the antistreptococcic serum.

Marmorek reports 15 cases of streptococcic infection in
puerperal women in which the serum was employed. In 7 of
these there was a pure streptococcic infection. This series had
no mortality. In 3 cases the colon bacillus was associated with
the streptococci. All these women died. In 5 cases pathogenic
staphylococci were associated with streptococci. In this number
there were 2 deaths.

Gaulard ^ reports two cases of puerperal fever treated by
serum. One was apparently benefited. The other died, although
the septic symptoms appeared to improve. While the tempera-
ture was falling, the patient was seized with bilious vomiting
and mctcorism, the pulse remaining as before, about 120. The
vomiting became uncontrollable ; she became comatose, and

' " Le Streptocoque ct le scium Antistreptococcique,'' Alexandre Mannorek,
•♦ Annalis de rinstitulc Parlour, " I. ix, July, 1895, P- 593-

'•' " Prcsse Medicale," Nov. 30, 1895.

I sign of suppuration or

PUERPERAL SEPSIS. 683

died on the thirteenth day. Gaulard believes that the serum was
the cause of the vomiting. He fears that too much serum was
injected, for at the autopsy there we
of peritonitis. The question of
maximum dose of the serum has
yet to be determined.

Bar and Tissier ^ have re-
ported further experiences with
the treatment of puerperal infec-
tion by antistreptococcic serum.
They report, in a preliminary
announcement, the treatment of
ten cases of streptococcic in-
fection by the antistreptococcic
serum. Of this number five died
and five recovered. Those that
ended in recover)' were compara-
tively light, and one would expect
a good result in such cases from
the older plans of treatment
They were, moreover, all treated
with intra-uterine irrigations,
which seems to have had more to
do with their recovery than the
serum injections.

Among the fatal cases was
one that received the first serum
injection three-quarters of an hour
after labor, and another in which
the patient died apparently from
toxemia after the symptoms of the
streptococcic infection had sub-
sided.

One can not avoid the thought,
in reading the history of this case,
that the serum was the cause of
death rather than the original dis-
ease. Its clinical features resem-
bled closely those of Gaulard's
fatal case.

At a meeting of the Philadelphia Obstetrical Society ' the mem-
bers reported 7 cases of their own treated by serum, and a col-

' " Fails pour servir i I'Histoire du tratlemenl de I'lnfcction pueiptrale par les
seram anlUlrcplococcicjues I'Obstrttrique," i, March, 1896, p. 97.
" " Am. Joiini. ObstBU," I897, vol. imv, pp. 635-650.

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684 PATHOLOGY OF THE PUERPERWM.

lection was made of 21 others with 7 deaths, a mortality of 25
per cent.

The judgment on the serum-therapy of streptococcic infec-
tion must at present run as follows : It requires a long time and
especially virulent inoculations to obtain a serum with antitoxic
and germicidal properties. It should be prepared, therefore, with
great care, and should be obtained from a thoroughly reliable
source. There is a possibility that this serum may contain danger-
ous toxins, and that the treatment may be more dangerous than
the disease. There is a streptococcic infection so virulent that the
antitoxin will be of no avail, no matter how strong it may be.
There is an undeterminable time in streptococcic infections, when
the serum will be used too late. The antistreptococcic serum has
no antagonistic power over other pathogenic micro-organisms.
It is not easy to determine during life whether the infection is
pure or mixed, though the majority of puerperal infections are due
to streptococci. Therefore, the use of the serum must be more
or less empirical. Finally, the clinical results of the serum-
therapy for puerperal infection have not been as yet at all en-
couraging.

The Treatment of Septic Infection by the Artificial Production of a
Hyperleulcocytosis. — A large and influential school of pathologists
regard phagocytosis as the agency by which an infectious disease
is spontaneously cured. It is logical, therefore, in those hold-
ing this belief, to attempt the treatment of septic infection by
stimulating the production of white blood-corpuscles that shall
serve as phagocytes. There are several agents administered in-
ternally that have leukocytotic powers, such as pilocarpin, albu-
mose, and nuclein. The first, however, is not advisable in sepsis
on account of its depressing action.

Hofbauer,^ from Schauta's clinic in Vienna, reports the results
of employing Horbaczewski's nuclein in seven cases of puerperal
infection. The cures affected in some of these cases certainly
warrant a further trial of the method. For two years I have
administered nuclein routinely as part of the treatment of puer-
peral sepsis, combined with local disinfection, stimulation, and
support, and in suitable cases with operative treatment.

To my mind, this plan of treatment gives promise of practical
results.

The Treatment of Sepsis by Washing: the Blood; Hypodermatociy-
sis ; Intravenous Injections of Saline Solutions. — A recent method
attended with marked success in the hands of physicians on the
Continent of Europe and in America. The best fluid for the

* '*Centralbl. f. Gyn.," No. 17, 1896, p. 441.

PUERPERAL SEPSIS. 685

purpose is 1 1/^ gr. CaCl, 1 1 J^ gr. KCl, to 34 oz. normal salt
solution. ^ Injections of large amounts — more than two quarts —
of this fluid into the bowel seem to give as good results as
hypodermatoclysis, and are much more convenient. The use of
the modified normal salt solution is a valuable adjuvant to the
other measures required in the treatment of puerperal sepsis.

The Operative Treatment of Sepsis in the Child -bearing: Period. —
Since the first performance by Tait of abdominal section for puru-
lent peritonitis there has been an extremely important develop-
ment, especially in the last decad, in the scope of pelvic and
abdominal surgery for septic inflammations during the child-
bearing period.

Regarded at first as a procedure analogous to opening an
abscess anywhere on the body, the whole abdominal cavity being
looked upon as an abscess-cavity and the abdominal walls as
its capsule, abdominal section for puerperal sepsis has become
a generic term of wide significance, including hysterectomy,
salpingo-oophorectomy, evacuation of abscesses in the peritoneal
cavity and in the pelvic connective tissue, removal of gangrenous
or infected neoplasms of or in the neighborhood of the parturient
tract, and exploratory incisions.

Indicatiotis for Abdominal Section in the Treatment of Puer-
peral Sepsis, — It is more convenient to deal generically with the
indications for abdominal section in the course of puerperal sepsis,
for the operation is usually decided upon in practice without refer-
ence to what may be required after the abdomen is opened, the
prudent and experienced obstetric surgeon holding himself in
readiness to perform any of the pelvic or abdominal operations
detailed above that may be found necessary when the abdominal
cavity is exposed to view and to touch.

In order to properly decide the important and anxious
question for or against celiotomy in the course of puerperal
septic fever, the medical attendant must be familiar with the
different forms of sepsis after labor, and should know which
of them are most and which are least amenable to surgical
treatment. In a general way, it may be stated that the opera-
tion is demanded most frequently for localized suppurative
peritonitis ; it may be indicated, and often is, for diffuse suppura-
tive peritonitis ; for suppurative salpingitis and ovaritis ; for sup-
purative metritis, if the inflammation extends outward toward

* See experiments of W. H. Howell, in Boston, on frog's heart ; modified Ringer
fluid. **The Use of Intravenous Saline Injections for the Purpose of Washing the
Blood," H. A. Hare, "Therapeutic Gazette," April 15, 1897. The technic of
the injection is the same as for the injections required in the treatment of the acute
anemia following severe hemorrhage.

686 PATHOLOGY OF THE PUERPERIUM,

the peritoneal investment of the womb or into the connective
tissue of the broad ligament ; for abscesses in the pelvic con-
nective tissue ; for infected abdominal or pelvic tumors. On the
contrary, abdominal section is contraindicated or is not required
in simple sapremia ; in septic endometritis of all forms — diph-
theric,^ ulcerative, suppurative ; in dissecting metritis, sloughing
intra-uterine myomata, or in suppurative metritis with the abscess
pointing into the uterine cavity ; in phlebitis, lymphangitis, and
in direct infection of the blood-current. One is most likely to
perform an unnecessary operation in diphtheric endometritis.
The writer has thus erred several times. By the time that
symptoms justify surgical intervention in this condition it is
always too late.

It is extremely difficult to lay down correct rules for the
guidance of a physician in a situation involving so much
responsibility, and of necessity so dependent upon many drcum-
stances. as that seeming to require a very serious surgical opera-
tion in the midst of an adynamic fever with, very likely, profound
depression, rapid pulse, high temperature — ^in short, with every-
thing a surgeon least desires in the face of a major operation.

First and foremost, then, the attendant should avoid the
operative treatment of puerperal sepsis if possible, and should
not seek an excuse for surgical intervention merely in the cardinal
symptoms of septic infection — high temperature, rapid pulse, and
general depression. He should demand some tangible evidence
of those forms of sepsis that arc amenable to surgical treatment.
But the physician of to-day, while reluctant to operate upon a
patient under the least favorable circumstances, and on his guard
against unnecessary or harmful surgery, must be prej)ared, in the
event of certain symptoms or complications, to operate with the
least possible delay.

riuis, on the very first appearance of symptoms that will
justify the diagnosis of diffuse suppurative peritonitis, the abdo-
men must be ()])cned without a moment's more delay than
is necessar}^ for an aseptic operation. Even with the utmost
promptness the operation will almost always be too late, for the
inflammation extends so rapidly and at first insidiously that by
the time a diagnosis is possible the progress of the disease can
not be stayed. It must be admitted, however, that an occasional
success is ])()ssible by timely surgical interference.^

' r>y diphtheric endoinctiiiis is meant a dirty, jjrayish- or greenish-brown
exudate <.>n ih<' iiidometiiiim. containin^^ mixed micro-orjjani.-nis, and not necessarily
the Klehs Lulller bncilhi^. Kor a rcj>urt of one aiul the mcnti(m of four cases of true
diphtheria of the genitalia se<; WiUiams, ** Amer. Jour, of ()l)stet.," Au^vust, 189S.

- Hirst, "A I >ift"use, l.'nliinite<l. Suppurative Peritonitis in a Child-tx>aring
Woman CupmI by Al>d' minal Section," ** Medical News," 1894. A unique case
in my experience.

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PUERPERAL SEPSIS, 68/

Again, in the presence of exudate, adhesions, or unnatural
enlargement of any pelvic structure, suppuration may be sus-
pected if the physical signs do not improve and i( the tempera-
ture, pulse, and general condition indicate a continuance of septic
inflammation. It is hardly necessary to state that if pus forms
it must be reached and evacuated irrespective of its situation.
Just how long to wait, however, is a question requiring experi-
ence, good judgment, and a special study of each individual case
for its correct answer.

Enormous pelvic and abdominal exudates may disappear ;
adhesions may melt away ; enlarged and inflamed tubes, ovaries,
and uterus may resume their proper size, functions, and condition
on the subsidence of the inflammation ; but in these favorable
cases distinct signs of improvement manifest themselves in a few
days, and the course of the disease is comparatively short. A
mere protraction of septic symptoms is in itself suspicious, along
with local signs of inflammation. Without the latter, the same
general symptoms, sometimes lasting for months, indicate phle-
bitis and infection of the blood-current. In this form of sepsis
an operation can do no good and may do the greatest harm.

In infected tumors in and near the genital tract the indication
for operation should be plain and the decision easy. The pres-
ence of the tumor should, of course, be known. On the first sign
of inflammation in it, or in the event of an elevated temperature
for which there is no good explanation, the tumor should be
removed. Early operations in these cases have furnished the
best results, delayed operations the reverse. ^ In cystic tumors
the likelihood of twisted pedicle should be remembered, and in
every case of child-birth complicated by a new growth the woman
should be watched with extraordinary care to detect the first
indication of trouble.

An exploratory abdominal incision should be made, as a rule,
only when it is desired to determine if a pelvic mass, presumably
containing pus, is situated within or without the peritoneal
cavity, and if the abscess had better be evacuated through the
abdominal cavity or extraperitoneal ly. In the early period of
experimentation with abdominal section for puerperal sepsis
I made exploratory incisions in obscure cases without any
local symptoms of inflammation in the pelvis or the abdomen,
and I have seen a number of such operations in the hands of
others. None of these operations yielded information of value,

* The most desperate cases, however, need not be despaired of. I have
successfully removed a gangrenous ovarian cyst from a puerpera who was so weak
that complete anesthesia was not attempted. The late Dr. Goodell had declined the
operation as necessarily fatal.

688 PATHOLOGY OF THE PUERPERWM,

nor did they benefit the patients. Consequently, it is a safe
rule not to open the abdomen of a puerpera for sepsis unless
there are physical signs of inflammation in the abdomen or
the pelvis.

Following these general statements in regard to abdominal
section for puerperal sepsis, it is now more convenient to describe
in detail the different kinds of operations required for the various
forms of intra-abdominal septic inflammations.

Abdominal Section for Intraperitoneal Abscesses and Diffuse
Suppurative Peritonitis, — The situation and extent of localized
suppuration within the abdominal cavity vary greatly. A
quarter of the abdominal cavity may be filled with pus, the huge
abscess-cavity being thoroughly walled off by dense exudate
from the rest of the abdominal cavity. A smaller accumulation
of pus about the orifice of the tube is not uncommon. In one of
my cases two or three abscesses the size of an orange were found
in coils of intestine quite far removed from one another, and with-
out apparent connection with the genital tract. In three cases
abscesses were found between the fundus uteri and adjoining
structures — ^the abdominal wall near the umbilicus in one, the
caput coli in the second, and the sigmoid flexure in the third.
In these cases infection had traveled through a sharply-defined
area of uterine wall and had appeared in the same limits on its
peritoneal investment. Exudate and adhesions immediately
walled off the infected area, with the result of an encapsulated
abscess between the uterine wall and the structure nearest to it
at the time of inflammation. The treatment of these abscesses
consists of their thorough evacuation, the cleansing of the cavity,
and drainage. The cleansing may be effected by flushing with
hot sterilized water, if the rest of the abdominal cavity can be
guarded from contamination. In some cases the writer has
avoided irrigation and in its place has thoroughly dried the cavi-
ties with gauze with good results. For drainage, as a rule,
sterile gauze will usually be found best. In certain cases of
abscesses near the abdominal walls a rubber tube answers better
than the gauze, and in deep-seated abscesses on the base and the
back of broad ligaments vaginal drainage by means of gauze or
rubber tube is much to be preferred. If the work during the
operation is well done, there may be little or no subsequent dis-
charge, and douching of the abscess-cavities during convalescence
is uncalled for. Occasionallv, however, if the abscess-cavitv is
very lari^c and well isolated, daily douching with sterile hot
water is an advantage. In diffuse suppurative peritonitis the
remote chance of success depends greatly upon the earliest pos-
sible operation, though there are many virulent cases in which

PUERPERAL SEPSIS, 689

nothing could check the spread of the inflammation and the deadly
effect of septic absorption.

This is not the place to discuss the symptoms of diffuse sup-
purative peritonitis, but one fact should be insisted upon from
the operator's point of view. It is usually supposed that true
diffuse suppurative peritonitis appears early after delivery ; it
may, however, develop at any time. I have seen it as late
as four weeks after confinement. The woman, who had been
up and about for some time, lifted an older child down a few
steps. The effort squeezed a few drops of pus out of one of the
tubes. The abdomen was opened within twenty hours, but to
no purpose. The technic of the operation is simple : A small
incision is made, and the finger is rapidly swept about the pelvis
and abdomen to determine the condition of the organs ; then
the irrigating tube is passed into the cavity at the lowest
angle of the wound, and is swept about in all directions, while
the return-flow is provided for by two fingers of the left hand
distending the sides of the wound, which by the fingers and the
irrigating tube is kept gaping as though by a trivalve speculum.
Gauze and glass-tube drainage into the pouch of Douglas and a
gauze drain in the flanks is provided for, and the wound is left
open, or, at most, drawn together by a stitch or two. Rapidity
of operation and the smallest possible quantity of anesthetic are
essential to success.

SalpingO'Odphorectotny for Puerperal Sepsis. — An acute pyo-
salpinx in the puerperium is very rare. It is uncommon for
acute septic infection after labor to travel by the tubes alone.
Infection usually occurs in the uterine muscle, the veins, the
lymphatics, or the connective tissue of the pelvis. When the
track of the septic inflammation is confined to the mucous mem-
brane of the genital tract, the pelvic peritoneum, in a case serious
enough to demand operation during puerperal convalescence,
becomes infected, inflamed, and suppuration quickly follows, so
that the operation is usually performed for an intra-peritoneal
pelvic abscess. The tube may be found somewhat swollen,
inflamed, and containing a few drops of pus, and its removal is
required ; but the pyosalpinx is a subordinate feature in the
pelvic inflammation. It is the more subacute case, not usually
requiring operation in the conventional period of the puerperium,
that results later in a typical uncomplicated pus-tube.

Ovarian abscess is much more common than pyosalpinx.
The infection may travel to the ovary, both by way of the
tube and by the connective tissue or lymphatics of the broad
ligament. In the latter case the whole ovary may be infiltrated
with a thin sero-pus of a particularly virulent character, and,
44

690 PATHOLOGY OF THE PUERPERIUM,

unfortunately, in excising the ovary the exposure of the infected
pelvic connective tissue in the stump may lead to infection of
the peritoneal cavity and to a diffuse suppurative peritonitis.

The commone^st indication for salpingo -oophorectomy is fur-
nished by a pus-tube antedating conception. The strain of
labor excites a fresh outbreak of inflammation or leads to its
spread, and the persistence of septic symptoms with the physical
signs of pelvic inflammation justifies operative interference. In
one exceedingly instructive case under my charge an operation
was performed on a presumptive diagnosis of old pus-tubes,
the diagnosis being based mainly upon the patient's history
and the existence of serious septic symptoms, with tender-
ness on abdominal palpation over the region of the tube and
ovary. The uterus was much too high in the abdominal cavity
to permit of a satisfactory pelvic examination of the uterine
appendages. On opening the abdomen, a pyosalpinx was found.
The patient recovered.

There is often nothing peculiar in the technic of these opera-
tions. They differ, usually, in no respect from similar operations
upon non-puerperal patients. The question of removing the
uterus along with the tubes arises, however, rather more fre-
quently than in the non-puerperal woman, on account of the
infection of the endometrium or of persistent metrorrhagia.
But in associated suppurative salpingitis, ovaritis, and infection
of the connective tissue of the broad ligament, there is a modifi-
cation of the ordinary technic, which is of vital importance.
The tubes and ovaries should be excised, the blood-vessels
of the broad ligaments tied separately ; the cut edges of the
broad ligament should be allowed to gape ; the whole pelvic
cavity should be filled with gauze and drained by a glass tube
placed just posterior to the uterus. The tube is sucked out by
a syringe at the end of twenty-four hours. Twenty-four hours
later the gauze is removed, the tube again sucked out and
removed, and replaced by a rubber drainage-tube, through
which the ])clvis is washed out daily with sterile water. I
have saved a number of the most desperate cases by this
technic.

Hysterectomy for Puerperal Sepsis. — The latest development
in celiotomy for puerperal sepsis is the removal of all the pelvic
organs and structures that can be removed when the septic
inflammation or suppuration involves the uterine muscles and
the broad ligaments. Eveiy physician who has seen many cases
of puerperal infection during operations or postmortem is aware
that there are some in which the mere removal of infected tubes
and ovaries or the evacuation of pelvic abscesses can not be

PUERPERAL SEPSIS,

expected to save the patient. There would be left behind areas of
infected and infiltrated broad ligaments that would commu-
nicate infection to the peritoneal cavity, or there would remain
foci of suppuration or infection in thi: uterine body that must
surely spread to the peritoneum or must result in septic metas-
tases. The only hope for the patient in such cases lies in the
entire removal of all infected areas, leaving behind in the pelvis
a healthy, non-infected stump. To effect this result the excision
of the uterus, the broad ligaments, the tubes, and the ovaries is
required, In addition to these cases there are others in which,
if the tubes and ovaries must be excised, the uterus might be
removed with advantage, on account of an infected endometrium
or of persistent metrorrhagia. Figure 490 is an example of such
a case. The young woman from whom the specimen (I'as re-
moved had a double pyosalpinx following a criminal abortion.
For .seven weeks she had been bleeding persistently, and at

Fig, 490, — Hysterectomy fur purulent salpingiij^ tamhors cose).

intervals had a foul-smelling discharge, Although the body of
the womb was healthy and the endometrium alone was inflamed
and infected, it was obviously wiser to remove at once all source
of the trouble rather than to excise the tubes and ovaries and
then to treat separately at some trouble and risk an organ that
had become entirely superfluous. The result justified the pro-
cedure. There may also be such wide-spread suppuration and
disintegration of the broad ligaments, along with tubal inflam-
mation, that the complete removal of all the infected area is
more easily accomplished, e.specially as regards the control of
hemorrhage, by a hysterectomy. Figure 491 represents such a
case. In this woman a pyosalpinx antedated conception. I^bor
excited fresh inflammation. The infection spread from the tube
downward through the connective tissue of the broad ligament,
resulting in a partial destruction of it, in a thick infiltration at its
base, and in an abscess between its layers, closely hugging the

692 PATHOLOGY OF THE PUF.KFERW.M.

whole of one side of the uterine body. It was obviously impos-
sible to remove the infected area in this case without removing
the womb as well. The operation, though undertaken under
the most discourajring circum.stances. was successful.

There can be no doubt as tn the necessity of hysterectomy

in such a case as that represented in figure 492. There were
abscesses in the uterine wall, directly under the peritoneal en-
velope, about to break into the peritoneal cavity ; one, indeed, did
rupture during the operation. There was a septic ulceration at
the placental site so nearly perforating the uterine wall that by a

light touch during the operation the forefinger passed into the
uterine cavity. There was also a pyosalpinx in this cast that,
judging by the history, antedated or was coincident with impreg-
nation. The operation saved the patient. In another success-
ful hysterectomy for puerperal sepsis, the author found the womb

PUERPERAL SEPSIS. 693

completely ruptured at the fundus from lube to lube. The diag-
nosis of the injury had not been made. The operation was
undertaken some weeks after labor, for what was thought to
be an intraperitoneal abscess. Areas of suppuration were dis-
covered, but the greater bulk of the infianimatorj' mass was
exudate which had shut off the general peritoneal cavity from
infection through the gaping uterine wound.

Indications for tlw Operation. — The indications for hysterec-
tomy during puerperal sepsis are furnished by the condition of
the pelvic organs when they are exposed to sight and touch after
the abdomen is opened. The four cases described above are the
types calling for hysterectomy, It is not often possible to deter-
mine upon hysterectomy before the abdomen is opened, but it
should be remembered that in any abdominal section for puer-
peral sepsis hysterectomy may be necessary. The careful ob-
stetric surgeon, therefore, should be provided with the implements

fig- 493'— Supp

required for amputation of the womb in every abdominal section
for puerperal sepsis, and should be prepared to remove the womb
for any one of the four indications described above, but should
rest content with the least radical measure that promises his
patient safety. The operation that is quickest done and shocks
the patient least is most successful, provided, of course, that it is
adequate.

Technic of lite Operalion. — There are two points in which the
technic of hysterectomy for puerperal sepsis may differ from the
technic of the operation performed for other conditions. One
of these points is the neces.sity often of doing pan -hysterectomy ;
the other is the necessitj' often of tying the ligatures in a broad
ligament much thickened by inflammatory exudate or byligating
the blood-vessels separately so as not to include an infected mass
in the ligature.

The author's preference is strongly for amputation of the
uterus, leaving as little cervix as possible, and this he always does

694 PATHOLOGY OF THE PUERPERIUM,

unless an examination of the cervix by a speculum shows septic
ulceration or exudate upon it or in its canal. The reasons for
this preference for amputation of the womb over pan-hyster-
ectomy are that the former can be done more quickly, there
is not the same anxiety about the cleanliness of the vagina,
and the suture material is more certainly guarded from infection
afterward.

The thickened broad ligaments are often a source of serious
embarrassment in placing and tying the ligatures around the
uterine arteries. There is this difficulty to contend with in the
majority of the operations. In two of my cases the inflamma-
tory exudate within and below the ligature broke down into
pus, but in both cases an incision in the posterior vaginal vault
evacuated the pus and secured an immediate disappearance of
somewhat alarming symptoms. In one case it was necessary to
do this as late as four weeks after the hysterectomy. Vaginal
hysterectomy is, in my opinion, usually unsuitable for cases of
puerperal sepsis on account of the danger of clamping large
masses of infiltrated and infected broad ligament.

Exploratory Abdominal Section for Puerperal Sepsis, — An
exploratory incision should be made only in cases of suspected
extraperitoneal pelvic abscess, to confirm one's suspicion, to be
certain that none of the pelvic organs, especially the tubes, are
diseased, and to determine the best situation for the incision
that shall evacuate the abscess-cavity without contaminating the
peritoneal cavity. This rule of practice would exclude ex-
ploratory abdominal .section in cases with no physical signs of
pelvic inflammation, but in which there is evident septic infec-
tion of a nature difficult to determine. There are possible ex-
ceptions to the rule, however, as in the case described on
page 691, of suspected pyosalpinx without physical signs,
owing to the high position of the recently emptied womb and
of its appendages.

Figure 494, drawn from life, represents a typical case requir-
ing exploratory abdominal section. The woman had a miscar-
riage some weeks before my first visit to her. She had lost
over thirty pounds in weight, was bedridden, had night-sweats,
high fever, profound prostration, and exacerbations of pain in
the pelvis. On examination, the usual symptoms of extra-
peritoneal pelvic exudate and suppuration were found on the
right side. When the abdomen was opened, it was found
that all the pelvic organs and the pelvic peritoneum were p)er-
fectly healtliy. There was a large collection of pus between the
layers of tlie rii^lit broad ligament, giving to this structure a
dome-shape. The tube and ovary running over the top of the

FUERFEKAL SEFSIS.

695

distended broad ligament were perfectly healthy and without a
trace of adhesion or inflammation of any kind. With the abdo-
men opened it was easy to locate the level of the anterior dupli-
cation of the peritoneum. A mark was made on the skin an
inch below this point, the abdominal wound was closed, an inci-
sion was made in the groin, as shown in the drawing, and the
pus washed out by douching. Sinuous tracts of suppuration
were found by the finger running up the psoas muscle and down
into the floor of the pelvis. Two drainage-tubes were inserted,
one upward into the psoas muscle, the other downward into the
pelvis. In the course of this woman's convalescence it was

found advisable to make a counteropening in the right lateral
fornix of the vagina, and to pass a drainage-tube through from
the opening in the groin to the vagina. In this way perfect
drainage was established, and the patient made a good recovery.
Cases of true extraperitoneal pelvic abscess due to puerperal
infection, and without intraperitoneal inflammation, a
There are some gynecologists who deny their existence, but
the writer has had six cases under his charge in which the
diagnosis was established by abdominal section.

696 PATHOLOGY OF THE PUERFERIUM.

The Morbid Anatomy and Clinical History, the Dlaffnoais
and Treatment ol the Different Forms of Infection and Septic
Inflammation of the Oenital Region After Labor. — ^The mani-
festations of puerperal sepsis differ with the various infecting
bacteria that are lodged in the genital tract or have invaded the
system, but especially with the organs or structures that are
involved in the septic inflammation. The terms, therefore,
"puerperal infection," "puerperal sepsis," or "puerperal fever,"
are generic in significance and include in effect a number of dis-
tinct diseases, widely different in their symptoms, their prognosis,
and their requirements for treatment. The lesions of puerperal
sepsis may be found in the mucous membrane of the genitalia
from the vulva to the abdominal orifices of the tubes, in the
mucous membrane of the bowel and of the urinary tract, the

Fig. 495, — Slreptococcus and sUphyJococcus nfecl on of Ihe endometnum: >i,
Necrolic layer of Ihe endometr um b zone of nflammalory read on ( gland
spaces ; d, lilood- vessels ; f, remnai ts of glandular ep Ihcl um (Bumm)

parenchyma of the uterus, the pelvic connective tissue, the peri-
toneum, the lymphatics, the veins, and in the parenchyma of
the ovaries. Neighboring organs and tissues may be involved
secondarily, as the bowels, ureters, and pelvic nerves, and tumors
of the pelvis and abdomen, if they exist, may be the starting-
point of septic infection and inflammation.

Encoipltis, Endometritis, and Salplniltls. — These inflamma-
tions arc most often of the superficial suppurative variety, in
which the prognosis is good, except in the case of the tubes,
whence t!ie inflammation may extend to the peritoneum, causing
diffu.se peritonitis or a ci re um. scribed abscess near the fimbriated
extremities, u.sually involving the ovar>', or a pyosalpinx.

The diphtheric inflammation of these membranes with an

PUERPERAL SEPSIS. 697

exudate and necrosis of tissue is less common and much more
dangerous. It may be localized in the vagina in the shape of
ulcers near the orifice or extending up the wall to the cervix.
It may be diffuse, occupying the whole interior of the uterus in
the shape of a yellowish -green, foul-smelling exudate, in which
streptococci, the bacillus pyocyaneus, the bacillus foetidus, and
the staphylococcus pyogenes albus may be found. In rare in-
stances the Klebs-Loffler bacillus may be discovered in the
pseudomembrane, showing that the case is one of true diph-
theria, and the diphtheria of the vagina may be associated with
diphtheria in the throat.^ If the diphtheric inflammation affects
the lower portion of the vagina, there is edema of the vulva in
at least two-thirds of the cases.

Diagnosis. — The diagnosis of these inflammations is made in
the cases of vaginitis by inspection, in salpingitis by a combined
examination, and in endometritis usually by the character of the
lochia, or by inspection of the cervical canal, which may be lined
with the same exudate that covers the endometrium. The diag-
nosis between pseudodiphtheric membranes and true diphtheria
can only be made by a bacteriological examination. It is most
important that this should be done, for cases of true diphtheria
should be isolated.

The treatment of these inflammations consists in frequently
repeated irrigations of the whole genital tract. The best mate-
rial for this purpose is sterile water without any antiseptic
agent, which latter simply diminishes the resisting power of
the body-cells without destroying the micro-organisms that are
the cause of the inflammation. In cases of septic endometritis
the systemic symptoms are grave, and a supporting, stimu-
lating treatment is required in addition to the local treatment.
In salpingitis a celiotomy may be demanded. If the inflamma-
tion is localized and the inflamed area accessible, it should be
touched with a nitrate of silver solution, 3j— 5j.

Metritis and Cellulitis of Subcutaneous and Pelvic Connective
Tissue ; Septic Metritis. — As a later stage of septic endometritis,
usually of the diphtheric variety, but possibly of the suppura-
tive, all the structures of the womb may be involved — connective
tissue, muscles, lymphatics, and often the veins, especially, how-
ever, the first. In the process of the inflammation portions of
the uterine muscle may be undermined by ulceration and may
slough off (dissecting metritis). A limited area of uterine tissue
may be involved, not larger in circumference, perhaps, than a

* J. W. Williams, five cases, ioc. cit.^ to which should be added one of my own,
with diphtheria of the throat in the husband and true diphtheria of the vagina in the
wife, demonstrated by bacteriological examination.

.irv vn^

rU m'^ijiiii

KMiu-L- and iiKlu.iL-

lin.r.iiM

.■ii>c>. «ukl:

y liiikivnt in llicir

ami tliH

r ivc]iiiri.'nK-

iits fur t natniai'

M-|lsis 11

i;n- Ih' fuiim

li in tlic iiiiicoi-

iVnnl till

,-"vuK.i I,.

llu' alnioniiiui'

IIIIU-OIIS

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u!" thi: bc.wel

iviiy by ■"
. Ix'sides if"-'
.uti.niofthtO'

..rfll-". ■

l)arL-ni:li\-ma i

-r thi

t.nK-iini,'thu
tiK' ovaries,
.sco.ndarily.a

lynip
sth

111" tliL- ]K'lvis an

|)oinl of sf[>tic i

Encolpltls,

liiaBU*':.'

^ ltniifnii.'is '-'1;!'^^'.,

inip'issibli- I" ''^"'..■.

absi'ess, by ■'«'t"..

:oiiiliini.'d tx.imrJii''^'

«~ -f it-i sitiialioii. . .

course ol llU'Su C.wsi>^';

f\- arc iiltimattlv 'lurtc '^'-^

.■J. f.:>r an al.sc<:ss a'lnm'^ '

;« oil the discasL'vl area 'A >«=

ce bctMvcii the Ht.:w^ ="■''

^-jcturcs attached t-i it. a-''^\

^ ,a-l or oniuiitiim. A bacierA

■ -.jininatinii f)f some of lln;*t ci'

.' i-wn tlic presence in the wX-^^

■'■ pyogenic staphylococci.

If the [x-hic connective tiss

.Avtid, it is at lirst edemat'ii

;[,]iiid is then absorbed, Icaviti'

iutiltnitc. if there h.»s been n

. vJisappeaiinfiir the cell-clement

-It Itn> extensive, is likewise a>

■^\ L-ases, OccasioiialK-, however

j .111 abscess resnlts, which may

-i:it. >■"■ throutjli tht: vafjiiial vai

:i! L-avtty. but wliicli i/mr riiptiir

699

%►

i very difficult to

ills feel boggy, and

ut it is almost impos-

unless one can feel an

examination, or unless

jrine cavity.

r the septic infection, the

J, easily determined. Ab-

J ulceration may so nearly

ator's finger is laid upon the

it penetrates at once into the

alitis is usually easy to establish.

A be felt on a vaginal examination.

able to decide whether the inflam-

-o the pelvic connective tissue, or

■um is also involved. If the exudate

•ide of the womb and does not involve

i the right to suspect pelvic cellulitis

s, but in my experience it has always

he abdomen before obtaining a positive

tially, septic metritis ends in recovery
collections into the uterine cavity, or by
(nation. The worst cases of the kind,
performance of hysterectomy. Cellu-
ity of cases to rest in bed, counter-
the lower abdomen, and hot vaginal
io so, an abdominal section should be
\yG sure that the peritoneum is not in-
lation is found, after the abdomen is
strictly to the pelvic connective tissue,
ould be closed, and the infected area, if
1 be opened by an incision above Pou-
gh the vaginal vault.
Diffuse Peritonitis. — Pelvic peritonitis is
sion from a suppurative or diphtheric
ugh the tubes or by extension directly
le womb, or it follows pelvic cellulitis,
the peritoneum between the endothelia
c interspaces. In an extension through
^ad of a cellulitis the ovary is likely to
ian abscess will develop. A leakage of
[large through the abdominal orifice of
( uncommon. It is followed by a sharp

698 PATHOLOGY OF THE PUERPERIU.M.

dollar. The inflammation extends directly through the uterine
wall, still confined within its original limits, until the peritoneal
covering is reached. Here the inflammatory process is also
strictly limited by the rapid development of adhesions which
bind the womb to those structures in the peritoneal cavity near-
est the diseased area. I have seen four examples in which the
uterus was anchored to the caput coli, the ajiterior abdominal
wall, and the sigmoid flexure. In these cases involution goes on
imperfectly, of course, for the womb can not be normally rc-

fduced in size, held as it is at a high level
in the abdominal cavity by adhesions.
There are, however, besides the fixation
and arrested involution of the womb, no
other local evidences of inflammation,
excepting some tenderness on pressure.
It is usually impossible to locate the
intraperitoneal abscess, by abdominal
palpation or combined examination, on
account of its situation.
The course of these cases is slow,
but they are ultimately quite certain to
be fatal, for an abscess commonly de-
velops on the diseased area of uterine
surface between the uterus and the
structures attached to it, usually tlie
bowel or omentum, A bacteriological
examination of some of these cases has
shown the presence in the uterine wall
of pyogenic staphylococci.

If the f)elvic connective tissue is in-
olved, it is at first edematous. The
liquid is then absorbed, leaving a dense
infiltrate, if there has been much cell-
proliferation, or entirely disappearing if the cell-element is scanty.
The infiltrate, if not too extensive, is likewise absorbed in
about four-fifths of all cases. Occasionally, however, in about
one-fifih of the cases an abscess results, which may be opened
above Pouparfs ligament, or through the vagina! vault without
entering the peritoneal cavity, but which may rupture into the
abdominal cavity, or may perforate the rectum, bl.iddcr, vagina,
or uterus.

In ca.ses of cellulitis from diphtheric or erj'sipelatous inflam-
mation the edema rapidly becomes seropurulent, in the fonner
case the inflammation rapidly becoming diffuse, in the latter
pos.sibly being limited.

Fig, 496, — Dissecliog
melnlis, S]iecimeii exjielled

by a, K al the Nev

York Maternily Haspilal 01
October lo, 1883, the Iwenty-
sixih day after conlinemt^nt.
ThJB was tlie eighth ci
the report published i
" New York Mcdicul Rce-
otA" vol, xxi«, p. 664 (Gar-
rigiies). (Thefigureis two-
thirds natural siie.)

PUERPERAL SEPSIS. 699

Diagnosis, — The diagnosis of metritis is very difficult to
make. The womb is large in size, the walls feel boggy, and
the uterus is very sensitive to pressure ; but it is almost impos-
sible to be positive that metritis exists unless one can feel an
abscess in its walls by an intra-uterine examination, or unless
the collection of pus breaks into the uterine cavity.

If the abdomen must be opened for the septic infection, the
condition of the womb is, of course, easily determined. Ab-
scesses may be seen in its walls, and ulceration may so nearly
perforate them that when the operator's finger is laid upon the
peritoneal covering of the womb, it penetrates at once into the
cavity.

The diagnosis of pelvic cellulitis is usually easy to establish.
The exudate and infiltration can be felt on a vaginal examination.
It is usually, however, impossible to decide whether the inflam-
mation is limited strictly to the pelvic connective tissue, or
whether the pelvic peritoneum is also involved. If the exudate
is situated only upon one side of the womb and does not involve
Douglas' pouch, one has the right to suspect pelvic cellulitis
without pelvic peritonitis, but in my experience it has always
been necessary to open the abdomen before obtaining a positive
answer to this question.

Treatment. — Occasionally, septic metritis ends in recovery
by the discharge of pus-collections into the uterine cavity, or by
the resolution of inflammation. The worst cases of the kind,
however, demand the performance of hysterectomy. Cellu-
litis yields in the majority of cases to rest in bed, counter-
irritation, poultices over the lower abdomen, and hot vaginal
douches. If it fails to do so, an abdominal section should be
performed, in order to be sure that the peritoneum is not in-
volved. If the inflammation is found, after the abdomen is
opened, to be confined strictly to the pelvic connective tissue,
the abdominal wound should be closed, and the infected area, if
it has suppurated, should be opened by an incision above Pou-
part's ligament, or through the vaginal vault.

Pelvic Peritonitis and Diffuse Peritonitis. — Pelvic peritonitis is
the result of the extension from a suppurative or diphtheric
endometritis, either through the tubes or by extension directly
through the tissues of the womb, or it follows pelvic cellulitis,
the germs penetrating the peritoneum between the endothelia
or through the lymphatic interspaces. In an extension through
the tubes or by the spread of a cellulitis the ovary is likely to
be involved, and an ovarian abscess will develop. A leakage of
lochial or catarrhal discharge through the abdominal orifice of
the tubes is by no means uncommon. It is followed by a sharp

yOO PATHOLOGY OF THE PUERPERIUM.

localized peritonitis, though it is not certain that the discharge
is always septic. It may be simply irritating. The infected or
irritated region may be surrounded by large areas of peritoneal
exudate, thrown out as a barrier against the spread of the oflfend-
ing substances. A large section of the abdominal cavity, one-
fourth or more, may be thus, as it were, solidified.

On palpation, the abdominal contents feel hard as stone, with
the muscles of the abdominal wall involuntarily fixed over them
for protection, on account of great sensitiveness to pressure.
Occasionally, the exudate communicates to the finger a sensation
as though snow were being kneaded through a covering of some
flexible material. The symptoms are not alarming, and the
common termination of this kind of peritonitis is recovery. The
exudate is absorbed, the tenderness disappears, the temperature
sinks to normal, and no ill-effects are left behind ; but the exu-
date may break down and encapsulated abscesses may thus be
formed, opening into the bowel, into the bladder, through the
abdominal walls at the umbilicus, or possibly undergoing caseous
changes.

General peritonitis after labor may result from an exten-
sion of pelvic peritonitis ; from infection through rents in the
vaginal or uterine walls ; from the rupture of old pus-collections
in the tubes or elsewhere in the pelvis ; from putrefaction of
tumors in the pelvis, as of dermoids and fibroids ; from the
transmission of infecting germs by the lymphatics, and from the
extension of septic inflammation through the bladder-walls.

If the suppurative peritonitis is not limited, the intestines
are lightly glued together ; are bathed in a thin pus, which
lies in pools between their coils ; are covered with a yellowish
exudate, which can be stripped off", leaving a raw, bleeding
surface.

There is a form of septic peritonitis so virulent and poisonous
that no signs of inflammation accompany it, and the patient dies
before pus or exudate can be formed (^peritonitis lymphatica).

The abdomen is found, after death, filled with a dirty fluid,
composed of serum, some blood, and numberless micrococci.

In all forms of septic peritonitis the coats of the intestines
arc paralyzed and tympanites is marked.

Diagnosis. — The diagnosis of pelvic peritonitis is made by the
general symptoms and by the local physical signs. There is
fev^cr of varying degrees, with accelerated pulse and general
depression. There is marked tenderness over the lower ab-
domen, and there is tympanitic distention of the abdomen. On
making a vaginal examination exudate is found in Douglas*
pouch and to the sides of the womb, which is firmly fixed. The

PUERPERAL SEPSIS.

701

exudate is usually exquisitely sensitive to pressure. It is some-
times firm and hard, and, again, may be soft and boggy. If the
latter condition persists, it is indicative of suppuration.

General peritonitis is usually sudden in its onset and very
rapid in its course. It occurs ordinarily in the first few days of
the puerperium.

There is extreme distention of the abdomen ; a rapid, running,
wiry pulse ; an extremely anxious, pinched expression of the face ;
a peculiar grayish color of the skin, and, perhaps, high fever,
agonizing pain, and possibly dullness on percussion at certain
points in the abdominal cavity ; but the latter signs may be en-
tirely absent. Theremaybeabsoiutely no tenderness nor pain, no
dullness, and very little fever. I have seen most malignant cases
end fatally within forty-eight hours from the first appearance of
symptoms, with a temperature never exceeding iooJ^° by the
mouth, though the rectal temperature is often much higher.

£Si'.

103°

lor

100°
89°

;

■s

: :

I^S' 497' — Temperature chart ordilTuse pnnilent peritonitis.

Treatment. — It is difficult to determine at first whether a
pelvic peritonitis will end in suppuration or resolution. As the
latter is always possible, the treatment should at first be expec-
tant. Counterirritation and poultices may be used over the
lower abdomen ; the bowels may be thoroughly drained by a
strong purgative, so as to diminish intra-abdominal congestion
and inflammation, and copious hot vaginal douches may be given.
If the symptoms persist much beyond forty-eight hours in their
original intensity under this form of treatment, suppuration has
probably occurred, or must be expected. In such a case the
abdomen should be opened. Abscesses, if they are found, must
be evacuated and the cavities thoroughly cleaned, disinfected,
and drained. Distended tubes and ovaries must be removed,
and it may be necessary to perform hysterectomy.

702

PATHOLOGY OF THE PUERPERIUM.

General, diflTuse, suppurative peritonitis is almost invariably
fatal, let the treatment be what it may. The only possible chance
for such a case is in the earliest possible performance of an
abdominal section with free irrigation of the abdominal cavity;
but even though this be doni; within twelve hours of the onset
of symptoms, it will almost invariably be of no avail. Once in a
long while, however, a case of true diffuse suppurative peritonitis
may be saved by a timely operation, as I know by personal
experience. I am, therefore, in favor of
surgical intervention in these cases, although
the surgeon should protect himself by in-
forming the family o^ the comparatively
hopeless nature of the case.

Uterine and Para-uterine Phlebitis. — The
veins of the uterus and of the surrounding
connective tissue are prone to thrombosis by
reason of the sluggish circulation, the pres-
sure during pregnancy, and the altered con-
stitution of the blood in a puerpera. The
clots, when formed, may become directly
infected, usually at the placental site. They
may then become disintegrated and swept
into the circulation, producing pyemia, or
the veins may become infected from passing
through a septic region. Then the walls
are first involved, the blood clots, and per-
haps thus opposes the further spread of the
process. Or, more likely, the clot is in its
turn infected, disintegrated, and carried into
the larger venous trunks. In the course
of the inflammation clots may become dis-
lodged or vessel-wails may be perforated
Ifroin specimen in ihe and a most sertous hemorrhage may resulL
Army Medicnl Museum, Repeated bleedings may occur at short or
Wasliingion. I). C). j^j^^ intervals. This form of septic infection

is least likely to produce peritonitis or local
inflammation in the pelvis, but is most likely to produce pyemia.
If infected emboli are swept into the circulation, thej' may
find lodgment in many difierent parts of the body, produdng
abscesses in the abdominal viscera, the eyeballs, the brain or
spinal cord, the lungs, the pleura, or in the subcutaneous con-
nective tissue at any portion of the body-surface. I have seen,
for example, the whole anterior portion of the left leg and the
right forearm riddled with the abscesses of suppurative cellulitis
in the course of a case of puerperal phlebitis.

Fig. 498.— Clots i.

PUERPERAL SEPSIS.

«*-'

Fig. 499. — Section through the placenlal site of a pueipera who died an the
eighth day from embolic pneumonia (thrombotic fonn of infeclion) : a. Necrotic de-

cidua, with colonies of streptococci and saprophytes ; *, thrombus in a vein opening
at the placental site ; <-. zone of inHaminatary reaction; d, section of a uteroplacental
artery ; i, muscular tissue ; f. continuation of the (hrombus, b, in which colonies of
streptococci are soFtening and breaking doirn the clot (Bumm).

,.. 4/^ ,

704 PATHOLOGY OF THE PUERPERIUM.

The thrombosis in a puerpera is not always limited to the
veins of the uterus and of the pelvis. 1 have observed, for
example, a fatal case, death occurring on the seventeenth day
postpartum, preceded by convulsions and coma. It was not
known whether the woman had had fever after delivery. In the
postmortem examination the longitudinal and lateral sinuses of
the brain were found perfectly solid with thromboses. There
had been a very severe postpartum hemorrhage, and there were
evidences in and about the womb of septic phlebitis.

Kig. 501. — Sonened thrombus from tbe placenlal site in a cue of pjremia ; a.
Uterine tniucle ; b, vein wall intiUrated with celts, the endotheliuin becomitig occro-
lic ; f, tlie lhroml)u!i inliltraled with masses of streptococci and beginnicg to disinte-
grate (bumm).

An almost constant accompaniment of uterine and pelvic
phlebitis is phlegmasia alba do lens.

Diagnosis. — The characteristic signs of uterine and pelvic
phlebitis arc: a high, irregular, and long-continued fever; profound
depression and great rapidity of pulse, with an entire absence of
all local .symptom!! of septic infection or of septic inflammation.
The womb is normal in size, is freely movable, and involution
goes on uninterruptedly. Tliere is no tenderness, no tympany.
Any interference with tbe uterus, as in an attempt to disinfect
its cavity, occasions an exacerbation of the fever and may cause
a serious Jicmorrhage, The woman's face is apt to show a

PUERPERAL SEPS/S.

705

dusky flush on one or both cheeks, and red splotches appear on
other parts of the body, especially upon the chest.

In the course of the disease evidences of pyemia may appear,
and phlegmasia alba dolens will almost surely develop, either as
the predominant symptom or as a mere incident in the course of
the disease.

Treatimvl. — The treatment of phlebitis should consist of a

preliminary disinfection of the uterine cavity. In a perfectly
typical case this will prove unnecessary or even harmful, but it
is so difficult to determine whether or not there remains in the
womb some infecting material, that the risk of doing the patient
some damage should be incurred in order to escape the serious

706 PA THOL OG Y OF THE PUERPERIUM.

error of leaving in the womb material which, if not removed,
may result in the patient's death.

The successful treatment of the phlebitis itself consists of
absolute rest and stimulation. Enormous quantities of alcohol
may be used with advantage, and as much food of an easily
digested character should be administered as the patient can
assimilate. The vast majority of these cases end in recovery,
but the disease may run a course of weeks or months.

Phlegmasia Alba Dolens, or Milk-leg. — This condition receives
its name from the appearance that the leg presents, and from
the old idea that most of the inflammatory conditions of the
puerperium were due to a metastasis of milk. There are two
distinct kinds of phlegmasia after delivery. In one there is an
occlusion of the veins of the pelvis and of the lower extremities,
interfering with the circulation and leading to an intense edema.
The leg is enormously swollen ; the skin is tense, glistening, and
milk-white in color. The swelling is so great that the skin does
not at first pit on pressure. In the other class of cases there is
a septic inflammation of the connective tissue of the pelvis and of
the thigh, the infection spreading from the perineum or from the
deeper pelvic fascia through some of the larger foramina of the
pelvis. Cases of the first class — thrombotic phlegmasia — are much
more common than those of the second — cellulitic phlegmasia.

Thrombotic phlegmasia should be also divided into two
classes. In one the thrombosis is primary, and is due to the pres-
sure to which the blood-vessels are subjected during pregnancy,
to Extensions of thrombi from the uterine sinuses, to stagnation of
the blood-current. In the other there is a septic inflammation
of the blood-vessel wall, leading to secondary thrombosis. The
clinical manifestations are quite distinct in the two kinds of
cases ; in the first there is little fever and few systemic symp-
toms ; in the second the fever is high and the systemic symp-
toms grave, but one often sees the first pass into the second by
an infection of the blood-clot.

Symptoms. — Usuajly from the tenth to the thirtieth day ^ there
develops a heaviness and stiffness in the leg, with pain, especially
in the calf of the leg, soon followed by swelling, beginning at
the ankle and gradually ascending to the groin, if the phlegmasia
is due to thrombosis of the veins ; or at Poupart's ligament or
the buttocks, extending down the thigh, if the condition is due to
a septic inflammation of the connective tissue. In the former
case there is very likely to be tenderness along the course of
the femoral vein, which may also be marked by a line of inflam-

^ Phlegmasia may antedate labor, and I have seen it make its appearance seven
weeks after delivery.

PUERPERAL SEPSIS, JOJ

matory redness. Other superficial veins may be likewise affected,
and may appear as red streaks under the skin. The lymphatics
may also be involved, and may be thickened and reddened.
There is almost always slight fever, which usually precedes the
swelling of the leg and disappears commonly long before the
swelling subsides. There is also gastric and intestinal disturb-
ance, with a foul tongue, loss of appetite, nausea, and vomiting.
There is profound physical depression, sometimes with great
restlessness and sleeplessness. There is often a dusky flush
upon one or both cheeks.

Phlegmasia is a very frequent complication of septic phlebitis,
in which disease it may occur as a mere incident, the swelling of
the leg appearing, perhaps, during the height of the septic fever,
lasting a comparatively short time, and disappearing entirely
long before the subsidence of the other symptoms of the septic
infection.

The left leg is more frequently affected than the right.
Occasionally, one leg is involved after the other, and possibly
they may both be swollen at the same time.

Frequency. — Phlegmasia is a comparatively rare disease.
There are many general practitioners in active practice who have
not seen a case. I have in my possession the records of more
than twenty-five cases that have occurred under my own obser-
vation. The majority of general practitioners, therefore, may
expect to encounter this condition once in a while.

As already stated, the thrombotic variety of phlegmasia is
very much more common than the cellulitic kind. Of my
twenty-five cases, only one was of the latter sort.

Causes. — The commonest cause of phlegmasia is a septic in-
flammation of the blood-vessel walls, beginning at the placental
site and extending through the pampiniform plexus down to the
femoral vein, or upward through the spermatic vessels to the
vena cava.

In consequence of the inflammation of the vein-walls the
blood clots in the vessel, and the clot extends even more rapidly
than the inflammation of the vessel-walls. Occasionally, the
thrombus is the primary occurrence. This is proven by those
cases which develop before labor. In these instances the
pressure of the pregnant womb upon the pelvic vessels, the
stagnation of the blood-current, and the composition of the
blood all conduce to the formation of extensive clots. But
even if the primary occurrence is a thrombosis, the clot usually
becomes infected in time ; so that almost every case of phleg-
masia, some time in its course, is septic in its nature. It has been
recently claimed by a German observer (Widal) that the throm-

708 PATHOLOGY OF THE PUERPERIUM.

bus of the femoral vein after child-birth is to be explained by the
presence of pathogenic micro-organisms in the blood, which
fasten themselves upon the vein-wall in the region of Poupart's
ligament, where the circulation is sluggish and stagnant, espe-
cially when the woman first stands up, and is favorable, on this
account, to the deposition of bacteria along the walls of the
blood-vessel. This theory very likely has some truth in it It
would explain the occurrence of phlegmasia in the course of
infectious diseases, such as typhoid fever and grip ; and it
would also explain the thrombosis of other vessels than those
in the pelvis, as, for instance, of the sinuses in the brain.

Prognosis, — The outlook in a case of phlegmasia is always
somewhat doubtful ; the dangers are manifold. There may be
pyemia from the detachment of a portion of an infected clot ;
abscesses may develop in the vessel itself, extending rapidly to
surrounding structures until the thigh-muscles are dissected one
from the other by an ulcerative process and the whole limb
becomes infiltrated with a foul sero-pus. The circulation may be
so interfered with that gangrene of the limb occurs, or the
vena cava may be blocked up, practically cutting off the whole
lower portion of the body from its blood-supply by preventing
the return flow. Or, if there is only partial compensation for
the obstructed circulation, there is a chronic congestion of the
limb, which is permanently enlarged and stiffened, and will
swell beyond its usual proportions if the woman is much upon
her feet. The passive congestion, if long continued and exag-
gerated in degree, may even result in the development of
elephantiasis.

Most to be feared of all is the detachment of a large portion
of the thrombus and a consequent pulmonary embolism, with
sudden death.

The most favorable course in these cases is absorption of the
thrombus and the restoration of the circulation through the
obstructed blood-vessel. The next most favorable termination
is a firm organization of the thrombus, the obliteration of the
vein, and a satisfactory compensatory circulation by means of
the gluteal vessels or through the epigastric veins.

Treatment. — The most important features of the treatment
may be outlined as follows : Order absolute quiet and rest flat
upon the back in bed, in order to avoid embolism ; elevate the
limb, in order to facilitate the return circulation as much as pos-
sible ; wrap it in cotton, so as to alleviate the feeling of cold and
numbness in it ; and support the system by sufficient food and
carefully rc[^ulatcd stimulus, as the disease is almost always
asthenic in tendency.

PUERPERAL SEPSIS.

709

Wlien all symptoms have subsided, when the swelling has
disappeared, and there is no longer the slightest tenderness along
the course of the affected vein, the limb may be restored more
quickly to usefulness by gentle friction and massage. The patient
should not be allowed to leave her bed until about ten days after
the complete subsidence of al! symptoms, for fear of embolism.
which is always possible until the clot lias become absorbed or
is firmly organized.

In the cellulitic variety of phlegmasia the fever is much
higher, the disease is more acute, and the inflammation more
intense. There is almost a certainty of suppuration in the con-
nective tissue of the thigh. The first formation of pus should

be carefully watched for, so that the abscesses may be opened
in time to avoid extensive burrowing. E.\tensive and multiple
incisions may be required to evacuate the pus and to drain the
diseased areas, even early in the course of the inflammation.

Abscesses may also develop, in the phlebitic and thrombotic
variety of phlegmasia, along the cour.se of the femoral vein, in
the popliteal space, or in the calf of the leg.

Septicemia, Sapremia, or Putrid Absorption. — By these terms is
meant the absorption into the system of ptomains or toxins
generated by the putrefaction of hypertrophied decidua, shreds
of membranes, blood-clots, pieces of placenta, or of the lochial
discharge.

This is. in my experience, one of the most common forms of

710 PATHOLOGY OF THE PUERPERIUM.

septic fever after child-birth. To produce it the germs of putre-
faction— saprophytes — must gain access to the uterine cavity after
labor, which they usually do if there is a pabulum in that situation
on which they may feed. Occasionally, they are excluded from the
uterine cavity entirely, in spite of the presence there of lai^

Fig. 506.— Section ol
filled with streptococci -, b,
ducing necrosis (Uuium).

masses of putrescible material, as Is proved by cases in which a
fetal head remained in the uterus three months, a placenta seven
months, without disadvantage to the patient. Sapremia is quite
likely to appear late in the puerpcrium, when the woman begins
to move about in bed or to get up, causing the vagina to gape

PUERPERAL SEPSIS.

711
to the vagina

by the movements of her limbs, thus admitting
and even to the uterine cavity.

Of all the forms of septic trouble after child-birth, sapremia is
the least dangerous and the easiest cured. It may, however, at

\ '^^^

);

Fig. S07. — Streplococcic iDfeclion of the deciduaand lympbuics: a. Necrotic
decidua; b, lymph - spaces ; i, inflammatory reaction; d, Ifmph-chaDneU, infected
with streptococci ; t, superficial layer of the uterine wail ; /, peritoneal exudate, with
streptococci on the peritoneal surface of the uterus (Bumm).

any time develop into one of the forms previously noted, and
shotild never be neglected.

Symptoms. — Usually in the first three days after labor the
temperature rises and the pulse is accelerated. The womb

712 PA THOLOG Y OF THE PUERPERIUM.

is found larger than it should be, and the lochia! discharge
has a foul odor. Often, however, sapremia may develop very
late in the puerperium. There may be no foul odor whatever
to the discharges, and the involution may appear to proceed
naturally.

Whenever there are general signs of septic intoxication
after labor, without evidences of local inflammation extending
to the uterine walls or beyond them, sapremia should be sus-
pected.

Treatment, — The treatment of this form of infection has been
described in the general treatment of all forms of sepsis. It
consists of the thorough disinfection of the parturient tract
The success of this treatment is, in the majority of cases, most
gratifying. All symptoms, though most alarming, may dis-
appear entirely within twenty-four hours.

Septic Cystitis or Ureteritis; Pyelitis. — These inflammations
may be of the superficial, suppurative variety, or they may be
diphtheric with the formation of a pseudomembrane.

In the latter case the exudate or membrane may extend from
the bladder by the ureter to the pelvis of the kidney. There
may be sloughing of the infected mucous membrane, putrefac-
tion of the masses of membrane exfoliated, and extension of
the inflammation through the bladder-walls to the peritoneum.
The kidney may bear the brunt of the attack ; it may be riddled
with abscesses, or converted into a large bag of pus. From
contiguity with the liver on the right side, hepatic abscesses may
also be found.

Diagnosis. — The cystitis usually develops a few days after
labor, with the ordinary signs of that affection — frequent and
painful micturition, slight elevation of temperature, pus and
mucus in the urine, and tenderness on pressure over the bladder.
The symptoms may subside after a few days and the patient may
appear to be in perfect health, but fever returns with added
intensity, and all the symptoms of septic infection may appear to
a most alarming; degree. The urine contains large quantities of
pus and mucus, and swarms with micro-organisms. There is
very likely tenderness on pressure over one or both kidneys, and
there may be intense pain in the lumbar region.

At this stage of the disease a stimulating treatment may
enable the patient to survive the immediate attack, though she
will probably be left with a chronic pyelitis that may impair her
health for the rest of her life. She is, however, very likely
indeed to die of the septic infection of the kidneys.

Infection of the bladder should never be allowed to extend
to the ureters and kidneys. On the first symptoms of vesical

PUERPERAL SEPSIS. 7 1 3

irritation and inflammation after labor, the bladder should be
energetically washed out and disinfected with a boric-acid
solution, or possibly with a somewhat stronger antiseptic. This
treatment usually stamps out the septic infection of the bladder
mucous membrane in a few days, and there is no extension of
the inflammation.

Septic Proctitis. — This rare disease may occur in conse-
quence of employing a badly infected syringe-nozle in the ad-
ministration of an enema. It is only likely to occur in hos-
pitals, and is extremely rare under any circumstances. I have
seen one case. The inflammation may be of a superficial
suppurative or catarrhal, or of a diphtheric character. The
latter is almost certain to be fatal. The former may end in
recovery.

Degeneration and i^trefaction of Pelvic and Abdominal Tumors.
— ^The cystic tumors of the pelvis and abdomen, usually
ovarian cysts, show a disposition to twist upon their pedicles in
the puerperium, and they may thus become gangrenous. Der-
moid cysts are particularly likely to undergo degeneration.
Solid tumors (fibroids), from the squeezing and bruising to
which they are subjected in labor, and from their low vitality,
are not unlikely to become gangrenous. The diagnosis of these
cases is not difficult. The presence of the tumor should be
recognized, and inflammation or degeneration in it must be sus-
pected if the patient develops fever and the signs of sepsis after
delivery.

The treatment consists of the timely removal of the infected
growths. If there is any elevation of temperature at all after
delivery, the tumor should be removed at once, without waiting
for indubitable evidence of degenerative changes in it.

Tetanus. — ^This rare disease of the puerperium is due to
an infection of the woman by the tetanus bacillus. The
micro-organism may be conveyed to her by a dust- laden atmo-
sphere, by actual contact with hands or implements that are
infected with the germ, or by muddy water containing a heavy
sediment of soil. The proximity of the lying-in room to a
stable was held accountable for the disease in one case. In
Vinay's 106 cases the placenta was manually separated in 20,
a tampon was inserted in 17.

Heyse^ claims that a tetanus infection is always a mixed
infection, and that the way must be prepared for the tetanus

i<<Uebcr Tetanus Puerperalis," "Deutsche med. Wochenschr. ," No. 14, p.
318, 1894. Other cases have been recently reported by Meinert, '•Archiv f.
Gyn.," Bd. xliv, p. 381 ; Maxwell, "Jour. Amer. Med. Association," xxxiii, p.
224; Irwin, **N. Y. Med. Jour.," p. 324, 1892.

714 ^A THOLOG Y OF THE PUERPERIUM.

bacillus by a preceding pathogenic germ, causing a septic endo-
metritis or some other pathological condition along the birth-
canal. This theory is not supported by the three cases under
my observation, in each one of which a most painstaking post-
mortem examination, conducted by a skilled pathologist, failed
to reveal any septic lesion of the birth-canal.

The disease may break out at almost any time after confine-
ment, but usually appears within the first two weeks. ^ It runs
a varying course, sometimes ending fatally within a few days,
in other cases lasting a number of days or weeks before the
symptoms become aggravated enough to permit of a diagnosis.
The fever may be very high, may be quite moderate, or may be
altogether absent until just before death.

The prognosis is extremely grave ; the mortality may be put
at about 90 per cent.^

A curious mistake in the diagnosis of this disease has been
brought to my notice on three separate occasions. In each of
these cases occurring at quite long intervals of time, seen each
by a different physician, the disease was taken for hysteria and
was so treated for a number of days.

The treatment consists of the administration of huge doses
of the bromids and of chloral, with stimulants, and in a disin-
fection of the birth-canal. If a reliable tetanus antitoxin could be
procured, it might be advisable to try this remedy, though one
of the cases treated with it in Philadelphia recently was appar-
ently killed by the treatment rather than by the disease itself.

Suppuration of the Pelvic Joints. — Any of the pelvic joints
may suppurate by the extension of an infectious inflammation
or by a metastatic infection. The symphysis is, however, most
often affected, usually in consequence of some injury during
labor, which lessens the resisting power of the joint. An early
diagnosis of suppuration in this locality should be made, and as
soon as the observer can convince himself that the joint contains
pus it should be freely opened and thoroughly drained.

The prognosis is fairly good.

ischiorectal Abscess. — Suppuration in the ischiorectal fossa
may occur in consequence of injury' to this region during labor.
I have one patient in whom an ischiorectal abscess developed
regularly after some four or five successive confinements. The

^ Vinay (" Du t^lanos puerperal," " Archives de Tocol.," 1892, p. 791) col-
lected 106 cases — 47 after abortion, 59 after labor at term. After abortion the disease
broke out in 21 cases during the first week ; in 16 during the second ; after labor in
19 cases during the first week ; in 23 during the second.

2 Vinay found a mortality of 88. 67 per cent. In surgical cases the mortality
has been 89.7 per cent.

PUERPERAL SEPSrS.

715

diagnosis of the condition is easy, and its treatment consists of
a free evacuation of the pus and in good drainage of the abscess-
cavity.

The Relation of Infectious Fevers to Puerperal Infection, especially
of Erysipelas, Diphtheria, Scarlet Fever, and Malaria. — A woman
after confinement is more susceptible to the infectious fevers than
she is at other times. Her lowered vitality and perhaps the
reception of the poisons of these diseases into the genital tract
make the period of incubation shorter and the disease itself more

iwi--

violent in its manifestations and more fatal in its results. Thus,
measles, a disease ordinarily of low mortality, becomes during
the puerperium a deadly malady.

It is therefore incumbent upon the practitioner of medicine
to abstain from ob.stetrical work altogether, if possible, while in
attendance upon cases of exanthematous fever or upon diph-
theria. It is not sufficient for the physician to depend alone
upon thorough disinfection of his hands and arms in such cases ;
his hair, clothing, skin, and breath may convey the contagion to

7l6 PATHOLOGY OF THE PUERPERIUM.

the puerpera, who will absorb it, perhaps, not only by the ordi-
nary channels, as by the throat in diphtheria, but also by the
genital tract as well.

Cases are reported in which a recently delivered woman had
at the same time diphtheritic exudate containing the Klebs-Lofflcr
bacillus upon the pharyngeal and upon the vaginal mucous
membranes. If a physician can not escape the necessity of at-
tending a woman in child-birth while in attendance upon conta-
gious diseases, he should take a full bath, should change his
clothing throughout, and should be as long as possible in the
open air afterward before he sees his parturient patient.

Erysipelas. — The connection of erysipelas with puerperal in-
fection may be dismissed in a few words. Modem bacteriologi-
cal research points to the identity of the streptococcus pyogenes
and the streptococcus erysipelalis. The production of pus and
internal inflammation or of an efflorescence upon the skin is simply
a question of virulence and of situation. It is not surprising.

Fig. 509. — Enlargement of a sectioD of tigure 50H, showing streptococci.

therefore, to hear of such experiences as those of Winckel, who
has found gcrm.s in abscesses of the pelvis after labor that on
inoculation produced erysipelas, and who has seen one of his
nurses, after catheterizing a febrile patient, develop erysipelas of
the face from a drop of the lochial discharge that splashed upon
her nose.

Other clinical facts are also easily explicable by the identity
of the pyogenic and of the erysipelatous streptococci. In the
course of puerperal infection, erysipelas may appear upon the
labia and spread thence down the thighs or over the trunk. If
the patient, on the contrary, contracts erysipelas in some portion
of the body remote from the genitalia, as upon the breast or
face, the disea.se may run its ordinary course without symptoms
of infection of the {genital tract and without great danger to life ;
but if the infection spreads to the genitalia or has its origin there,
the danger of death i.s great.

Diphtluria. — The connection between diphtheria and epi-

PUERPERAL SEPSIS. JIJ

demies of puerperal infection has been demonstrated beyond a
doubt by a vast amount of clinical observation. To select a
single example out of many : One of my young friends and
former students lost two healthy women in a week from puer-
peral sepsis while he was in attendance upon a child with diph-
theria.

He had never had a serious case of puerperal infection before,
and he has not had one since. The Klebs-Loffler bacillus has
been found in two cases of vaginal exudate under my notice in
Philadelphia. As already stated, the mere disinfection of the
physician's hands and arms is not enough to protect a woman
against this malignant disease. Complete change of clothing,
including the shoes ; a thorough soap and hot-water bath, with
scrubbing of the hair, face, and exposed portions of the body ;
brushing of the teeth, and gargling of the throat with an anti-
septic wash, such as listerine, and a purification of the lungs by
prolonged exposure in the open air, are precautions none too
great or troublesome to clear one's conscience of the dreadful
imputation of having destroyed the life that he is charged with
preserving, if he must attend a woman in child-birth while he
takes care of diphtheric patients.

Scarlet Fever. — The connection between scarlet fever and
puerperal sepsis is yet in doubt. Contrary to the opinion ex-
pressed by some authorities, scarlet fever in the puerperium is
rare. The comparatively frequent occurrence of septic erythe-
mata has led many observers in the past to believe that scarlet
fever is a common cause of septic infection after child-birth.
The same rule obtains in the case of scarlet fever in the puer-
perium that prevails in other infectious diseases during that
period — namely, the woman is more susceptible to contagion,
the period of incubation is shorter, and the disease is more dan-
gerous than at other times. During pregnancy the woman is
particularly resistant against the poison of scarlatina. She may
carry about with her, while pregnant, the poison of the dis-
ease, and may only yield to it after child-birth. As evidence
that the poison of scarlatina finds an entrance into the body
through the mucous membrane of the genital tract, it is inter-
esting to observe that in the puerperium the rash is more marked
upon the lower portion of the body, and that the throat symp-
toms may be entirely absent or very slightly marked.

Malaria. — The puerperal state excites almost surely a fresh
outbreak of malaria that is latent in the system, even though it
has been dormant for years. There is nothing to show that the
woman is likely to contract the disease during the period of
puerperal convalescence itself, but if she has ever had it in her

7 1 8 PA THOL OG Y OF THE PUERPERIUM,

past life, it is practically certain to break out before she rises from
bed.

The differential diagnosis of malaria and sepsis may be very
difficult to establish at first, but the past history of the patient,
the microscopical examination of the blood, and the therapeutic
test usually suffice to clear up all doubt within twenty-four
hours. To be on the safe side in doubtful cases, it is wise to
disinfect the genital tract, as well as to administer antimalarial
treatment.

PART VI.

OBSTETRIC OPERATIONS*

Induction of Abortion. — By the induction of abortion is
meant the interruption of pregnancy before the viability of the
child — that is, prior to the one hundred and eightieth day of
pregnancy.

Indications. — ^The induction of abortion should be undertaken
as reluctantly as one would commit justifiable homicide. If,
in the course of pregnancy, some disease arises as a direct
consequence of gestation, or if a woman suffering from dis-
ease is made much worse by the existence of pregnancy,
and if her life is distinctly endangered in consequence, it is
not only justifiable, but it is the physician's duty to terminate
gestation, and thus to save one life, and that the more valuable
of the two, instead of sacrificing both mother and fetus. The
following conditions occasionally furnish a justifiable indication
for the induction of abortion :

Pathological Vomiting, — When all the remedies for this con-
dition have been conscientiously and carefully tried without
avail, when rectal alimentation has been continued for a week or
ten days without marked improvement in the woman's condition,
and it is evident that she is in danger of death if her pregnancy
continues, the induction of abortion for uncontrollable vomiting
is justifiable.

Albuminuria and Kidney Breakdown. — If ominous symptoms
appear, such as progressive edema, persistent headache, steady
or rapid increase in the amount of albumen, sudden diminution
in the quantity of urine, casts in great number in the urine, and
failing vision, in spite of careful dietetic and medicinal manage-
ment, the induction of abortion is called for.

Death of the Embryo or Fetus. — If it can be demonstrated
that the embryo or fetus is dead within the uterus, its removal
is desirable ; but it must be remembered that the signs of fetal
death are difficult to elicit, and that a certain diagnosis can be

719

720 OBSTETRIC OPERATIONS.

made only after an observation extending over some days or
weeks, unless the membranes are ruptured and the fetal body
has begun to putrefy.

Certain Intra-utcrmc Diseases. — As pointed out in the sec-
tion on Intra-uterine Diseases, acute hydramnios and cystic
degeneration of the chorion villi may call for the induction of
abortion.

Uterine Hemorrliage. — Uterine hemorrhage, from placenta
praevia or from the detachment of an abnormally situated pla-
centa, may be so profuse or so long continued as to demand
the evacuation of the womb early in pregnancy.

Displacement of the Gravid Uterus. — Retroflexion, prolapse,
and anteflexion of the gravid womb, resisting other treatment,
and threatening to become incarcerated, call for the termination
of gestation.

Certain Nervous Diseases. — In the course of acute mania
and melancholia, or in chorea, and possibly in general pruritus,
the question of terminating pregnancy may be considered.

Certain Blood Diseases. — If pernicious anemia or leukocy-
themia arises in pregnancy or is made much worse by the
advent of pregnancy, the question of terminating the woman's
condition may arise for consideration.

In any of these indications the question is an anxious
one, and should not be decided by the attending physician on
his own responsibility, no matter what his experience or skill
may be. There should invariably be a consultation, so that the
responsibility may be shared and the oj>erator may be free from
criticism.

Methods of Inducing Abortion. — Many plans have been advo-
cated, but most of them have been found either too slow, too
dangerous, or ineffectual. Such are the administration internally
of ergot, rue, sabina, aloes, and of cotton-root ; injections upon
the cervix or between the membranes ; the insertion of inflated
rubber bags in the vagina or in the uterus ; rapid or gradual dila-
tation of the cervix ; perforation of the membranes ; injections of
irritating substances, as MonselTs solution, into the womb ; and
an electrical current.

The method employed by myself with satisfaction in a num-
ber of cases may be described as follows : The woman is ether-
ized and placed in the dorsal position upon an operating table.
The vagina and vulva are disinfected by tincture of green soap
and hot water and absorbent cotton, and by a douche of corro-
sive sublimate solution, i : looo. The anterior lip of the cervix
is fixed with a double tenaculum, and the cervical canal is dilated
to the size of the thumb with Hegar's dilators or cautiously with

INDUCTION OF PREMATURE LABOR. 72 1

branched dilators. An Emmet's curetment forceps is inserted
into the womb, opened and shut in several directions so as to
crush the ovum, and then withdrawn with whatever portion of
the ovum or embryo that comes with it. It is impracticable to
remove the whole ovum at once. An iodoform gauze tampon
is then packed in the lower uterine segment and in the cervical
canal, and a tampon of gauze or antiseptic wool is placed in the
vagina. The tampons remain in place twenty-four hours. On
their removal, if the remainder of the ovum is not yet discharged
from the external os, the cervix, now much softened and easily
stretched, is further dilated with larger bougies than were used
before, or by the fingers, and the uterine cavity is emptied of all
its contents as after an ordinary abortion by the curet, the finger,
and a placental forceps (Emmet's curetment forceps).

While the interruption of pregnancy before the one hundred
and eightieth day is called the induction of abortion, the method
just described is only practicable up to the fourth month. After
that time abortion is induced in the same manner as premature
labor.

Induction of Premature Labor — In addition to the indications
for the induction of abortion there are special indications for the
premature interruption of pregnancy after the child has become
viable. The most important of these is a contracted pelvis.
The next in importance, perhaps, is placenta praevia. It may be
necessary, in advanced phthisis, or in grave heart disease, to
secure the mother's delivery before term, in order that the child
may be born before the fatal termination of her disease, which
is evidently close at hand. Labor at term, or shortly after, may
be induced in a woman showing a disposition to prolongation of
pregnancy. Last of all, in the rare cases of habitual death of
the fetus just before term, it is advisable to induce labor before
the period at which the child's death may be expected.

Methods of Inducing Labor. — The following, founded upon
Krause's ^ method, is the best plan for use in the vast majority
of cases. The parturient tract is made aseptic by tincture of
green soap, hot water, and pledgets of cotton, and by an anti-
septic douche. An aseptic, stiff, silk or linen bougie (No. 17
French), which has been soaked for at least a half hour in
a cold corrosive sublimate solution i : 1000, is thoroughly
anointed with carbolized vaselin (5 per cent.). The patient is
placed in the dorsal position across the bed, her feet resting on
two chairs. The operator passes two fingers of his left hand
into the vagina, inserting one or, if possible, both finger-tips

^ ** Die kiinstliche Friihgeburt, monographisch dargestellt " von Albert Krause,
Breslau, 1855. *

722 OBSTETRIC OPERATIONS,

into the cervical canal. The bougie is then passed along the
groove between the two fingers until it enters the cervical canal
and passes into the lower uterine segment posteriorly. It is then
pushed further in until it has entirely disappeared within the
uterus, with the exception of an inch or a little more that pro-
trudes from the external os. An iodoform gauze tampon is then
packed lightly in the vagina, to keep the bougie in place. Active
and effective labor-pains begin in from thirty minutes to thirty-
six hours. In the majority of cases labor begins within twelve
hours. If it has not begun at the end of that time, a second
bougie should be inserted alongside the first. If, after twenty-,
four hours more, labor has not begun, the cervix should be arti-
ficially dilated with Barnes' bags, and, if necessary, the mem-
branes should be ruptured, forceps may be applied to the head,
or version may be performed and the child extracted by the feet

If the mother's condition demands immediate delivery, the
best method is as follows : The cervical canal is dilated forcibly,
the membranes ruptured, a forceps is applied, or version is per-
formed and the child is extracted by the feet.

The other plans proposed for the induction of labor have
not been satisfactory. The injection of glycerin between the
membranes, first proposed by Pelzer, and enthusiastically recom-
mended for a time, has proved dangerous, and is, moreover, not
to be depended upon. The use of dilatable bags in the lower
uterine segment should also be condemned, as they are unre-
liable and may burst.

FORCEPS,

Historical — Three years before the massacre of St. Barthol-
omew, in 1 569, there fled from France to England a Huguenot
family named Chamberlen. The head of this family, named
William, was a practising physician. He settled in South-
ampton, and raised a large family of children, two of whom,
both named Peter, took up the calling of their father, and became
physicians, goin^ up to London to practise their profession,
where they achieved great success. The younger Peter was in
continual conflict, however, with his brother practitioners, and
was many times summoned for reprimand and punishment before
the College of Physicians. On one of these occasions he was
accused of boasting that "he and his brother and none others
excelled in these subjects " (difficult labors). This was in the
beginning of the seventeenth century (16 16), and is the first
record of that secret which remained in the Chamberlen family
for more than three generations, which was the foundation of
their boast that they alone could be regarded as skilled obstet-
ricians, and which enabled them all to grow rich by the practice

FORCEPS. 723

of their hidden method of dealing with difficult labors. But
instead of being honored as the discoverers of one of the most
important inventions of medicine, posterity has condemned and
must condemn them that for their own gain they should have
deprived the world of knowledge that might have saved thou-
sands of lives and have prevented untold suffering during the
hundred years that the forceps remained a secret in their family.
The younger Dr. Peter Chamberlen had a son, also named
Peter, who was a most remarkable character : a man of great,
but ill-directed talents ; possessing some inventive genius ; an
-extensive traveler ; an accomplished linguist ; obtaining the
favor and friendship of the British royal family, and engaged
during the greater part of his mature life in a most lucrative
practice among the upper classes in London. It is to this
man, who made such a mark in his time, that the invention of
the forceps was formerly credited ; but there is no doubt, from
evidence recently come to light, that he inherited the secret
from his father, who, in his turn, obtained it from his elder
brother, Peter Chamberlen, senior.^ The idea that the younger
Peter invented the instrument was no doubt fostered by himself,
for he was a man of intense egotism. A short time before his
death he wrote his own epitaph, which began —

** To tell his learning and his life to men
Enough is said by, * here lies Chamberlen.' "

This Peter had a son, Hugh, who ailso studied medicine, and
to whom his father disclosed the family secret of the Chamber-
lens. Hugh, who was extravagant, determined to make the
most of his inheritance, and to part for a consideration with
the secret that had remained in his family so long. He accord-
ingly went to Paris and offered to acquaint Mauriceau with his
secret method of dealing with difficult head presentations, which
up to that time had been managed by tearing the child to pieces
with sharp hooks. For this piece of information Chamberlen
asked the enormous sum — ^for it was enormous in those days —
of ten thousand dollars (ecus). Mauriceau took the matter
under consideration, and, having one day a deformed dwarf in
labor, Chamberlen was asked to test his method in the case.
He did so, and failed completely, the patient dying from a rup-
tured uterus, undelivered. This ended the negotiation for the
sale of the secret in Paris. On his return to England Chamber-
len translated and published Mauriceau's book, with a preface
written by himself, in which he says : ** My Father, Brothers,
and my Self (tho none else in Europe as I know) have by God*s

1 " The Chamberlens," J. H. Aveling, London, 1882.

724.

OBSTETRIC OPERATIONS.

Blessing and our Industry, attained to, and long practised a
to deliver Women in this Case without aiiy Prejudice to them o
thdr Infants." Hugh Clianiberlen is next heard of in AmsterJ
dam, whither he had fled from England on account of som
financial difficulties, Htrc he had better fortune than in Paris«|
and succeeded in selling his secret to th<
College of Physicians of Amsterdam. '
institution immediately induced the govei
mcnt to pass a law which forbade any on
to practise medicine in the town who had
not given satisfactory evidence of posse
ing the secret now owned by the college^
and imparted to each aspirant for a medica'
degree who was able to pay for it.
traffic in the Chamberlen secret continues
until the middle of the eighteenth century^
when two public-spirited citi^tens ofAmstciu
dam, thinking it an outrage that a methtx
for which such extravagant claims
made should remain a secret, took a cc
in medicine, purcha.sed the knowledge r
quired of them from the College of Phy^-jJ
cians. and published it to tlie world. It waiH
a single blade of the obstetric forceps iT
Whether Chamberlen tricked the college a
the college cheated its students is
known.'

Before this time, however, certainly i
early as 1725. the true secret had leaked c
in ICngland. and during the middle of tin
eighteenth century the forceps came to 1
widely known and quite ffcnerally u.sed. There was for alo
time much speculation as to the kind of instrument that the Chains
berlens really invented, and there were many, some years a|^S
who doubted that the invention had been the forcejisata"
was thought at one time to have been a forcing powder or a blunl
hook. It was believed for a while that Jean Palfyn (1/ 16) hadjj
first conceived the idea of an instrument which was developi
later by others into the forceps. But these doubts have been set"'
at rest. At Woodham, Mortimer Hall, in Essex, owned and
occupied by Peter Chamberlen, junior, was discovered, in 1813.
a chest in which were found the instruments shown in figui

' Other slories arc thai Roonhuyien solil ihe sccrn in Kay«c1i nmi a nninlvi
olhcr? ; ihal a sludem of Koonhuysen's innde a suireiililioui rttowing nf ihff in*
mrn\ and )nib1i<ihe>t it ; that Jacob de ViHiher and Hugo van de Toll obuined
secret from the daughtei of n fortner posseasor.

Fig, 5 10, — Smellie's
straight forcep. An
eight eenlh crniur)' Eng-
lish fnrceps. Ihe blades
wrapped with lea I her,
thought tu keep them
from slipping.

513.' The Chamberlens were also the inventors of the vectis,
or lever, an instrument no longer made, for a single blade of the
obstetric forcqjs answers the purpose perfectly.

t'ig. 513. — Chunberlcii's vectis.

The Chamberlcn instrument had not been long known and
employed before certain defects were noticed in it. It was found

menls received all that
in of Ihc forceps aX Ibe
en in Ihc illiulmtioni.

726 OBSTETRIC OPERATIONS.

difficult to introduce it, especially if the head was high up in the
parturient tract. It was also found difficult to lock it, and the
necessity of binding the handles together was found to be
inconvenient.

The first of these disadvantages, the difficultj' of introduction,
was soon discovered to be dependent upon the curve of the pelvic
canal, and it was recognized that an instrument to be introduced
into this curved canat should
A B itself be curved to correspond

with the direction of the canal.
Almost simultaneously, in Kiig-
land and France, about 1750,' a
pelvic curve was added to the
forceps — in England by Smelltc,
in France by l^vreL Each of
these men, distinguished ob-
stetriciajis of their time, ailded
very important modifications to
the forceps, which are worthy of
careful attention, for the two
instruments known as the for-
ceps of I^vret and the forceps
of Smellie are the direct pro-
genitors of the two t>'pcs of for-
ceps in use at the present time.
The Knglish forceps, as may be
seen in figure 514. B, is small,
short, and light. It has, as
may be seen, the English lock ;
the pelvic curve is inadequate,
and to keep the instrument J
from slipping it was originally I
wrapped in leather; but the in-'
strument had good points about J
it, which are found modified ;
the modern Hnj^lish forceps of I
Simpson.

In the French forceps (Fig. 514, A), we find a heavy, lnng4
instrument, with powerful handles and closely approximated 1
blades. The lock is the pin or French lock, which the l-'rench J
forceps carry at the present time. In this instrument, too, the .
pelvic curve is inadequate, but the forceps has certain advan-

' Levrct prescnled his fori
first published a descriplion of h
IcD years befon.

I'iC- S'4' — -^' l-cvrel's forceps
wilh Bpelvici'urvc; B, Smellie's for-
ceps with B pelvic curre.

:cunc ^^—

FORCEPS.

727

tages, which, modified, may be found in many modem instru-
ments. It was not long before the disadvantage of the inade-
quate pelvic curve was appreciated, and soon after the time of
Smellie and Levret this feature was improved, and a forceps with
a better constructed pelvic curve came into use. It may be
noticed that the handles of both the Levret and the Smellie for-
ceps are rather difficult to grasp, if one desires to make a strong
traction upon them. This disadvantage was overcome by Busch,
a German, who was the first to add the cross-pieces or shoulders
to the handles, which enable the operator to take a firm and
convenient grip of the instrument.

It is plain that both the French and English locks each
possess some advantages and some disadvantages. The English
lock is easy of adjustment, but is not very secure. The French
lock is difficult to adjust, but when once fastened, is firm and

Fig. 515. — A, French, B, English, and C, German locks.

unyielding. Briinnighausen united the advantages of both these
locks and did away with their disadvantages in the lock known
as that of Briinnighausen, or the German lock (see Fig. 5 1 5).

Almost every eminent practitioner of obstetrics for the last
hundred years has added some modification of slight importance
to the forceps ; so that the patterns, differing in a slight degree
from one another, have been almost innumerable. There are
two types of modern forceps, however, that merit description —
that of Hodge in this country, and that of Simpson in Edin-
burgh. They embody the best features of the two distinct
classes that they represent. Hodge's forceps is the direct
descendant of Levret's ; Simpson's, of Smellie's. The Hodge
forceps has the advantage of taking an extremely firm grip upon
the child's head, and of allowing great power in extraction and
compression of the head. Its great disadvantage is that it may
injure the child's head more easily than almost any other modem

728 OBSTETRIC OPERATIONS.

instrument Simpson's forceps — in my opinion, the best modem
instrument for the ordinary case — has a cephalic curve so well
constructed that it can scarcely injure the child's head, even when
great force is used to extract it The pelvic curve is sufficient,
but is not so great as to embarrass the operator when the instru-
ment is applied to the head low down in the pelvic cavity. The

Fie- 519.— Smnll f(

blades are of such length that the instrument may be used with
equal convenience at the superior strait or at the pelvic outlet.
The lock is the English lock, which has the threat advant^e of
easy adjustment ; and the handles are provided with shoulders
for two fingers, and with depressions along the handle for the

FORCBFS. 729

remaining fingers and thumb of the hand, so that a firm and con-
venient grasp can be taken of the instrument in use.

Another modern instrument deserving description is the
Davis forceps, very carefully constructed upon iron models of
the fetal head. If this Instrument is carefully adjusted to the
sides of the normal child's head in the pelvis, it is no doubt pro-

Fig, gzo. — Showing the direclioa in which Iraction must be made by the handles,
■nd the conespondence of the direction in traclion upon ibe traction -handle and the
direction in which the head ir"-'

Fig. 5ZI. — I-Iermann's forceps.

vided with a better cephalic curve than any other forceps ; but
if it should not be applied accurately to the sides of the head, it
is capable of doing the child's head great damage. A very use-
ful instrument also in the author's experience is a light, short
forceps for use at the parturient outlet.

As the mechanism of labor was better appreciated, and the
forceps came into more general use in the latter part of the

732 OBSTETRIC OPERATIONS,

muscular effort in the second stage of labor in valvular disease
of the heart.

Finally, labor may be obstructed by abnormal positions of
the cephalic extremity, or by anomalies in the mechanism of
labor, as, for example, in face presentations when the chin does
not rotate forward, or in vertex presentations when the head is
insufficiently or excessively flexed.

A good rule of thumb to govern the obstetrical practitioner is
to apply the forceps in head presentations whenever the presenting
part remains stationary for two hours in the second stage of labor.

It is quite as important to recognize the contraindications to
the use of the forceps as it is to understand when the instrument
is needed. The contraindications to the use of the forceps, ex-
pressed dogmatically as rules of practice, are as follows :

The forceps must not be applied unless the os is dilated.
There are exceptions to this rule. When the maternal or fetal
life is threatened, it may be permissible to apply forceps through
a partially dilated os, as, for example, when rupture of the
uterus is threatened. It may be necessary, in some cases of
rigid cervix, to dilate the os artificially by applying forceps and
pulling the head down upon the cervix. It is also necessary, in
cases of valvular disease of the heart and in the adynamic fevers,
to shorten labor as much as possible by applying forceps to the
head through an undilated os and rapidly extracting the child.

The forceps must not be applied until the head is engaged
in the superior strait. This rule, too, admits of some excep-
tions. It is rarely possible to fix the head in a contracted pelvis
with forceps, when the powers of nature are insufficient to attain
this end. It is also justifiable to apply the forceps to the head
loose above the superior strait in cases of placenta pracvia
with the head presenting, and to bring it down as a tampon in
the pelvic canal.

The forceps must not be applied until the membranes have
been ruptured. This rule admits of no exception.

The forceps must not be used as tractors in impossible posi-
tions and presentations, as, for example, face presentations with
the chin posterior.

The forceps must not be employed unless the head be of
average size. If the fetal head is too large or too small, the
instrument is apt to slip and to inflict dangerous injuries upon
the maternal soft parts.

The forceps must not be used when the disproportion be-
tween the head and the pelvic canal is too great.

In sclectin^:^ an instrument, the author would recommend the
beginner, if he must restrict himself to a single forceps, to pur-

FORCEPS. 731

eyelets in the forceps blades, and fastened to a handle bent at
right angles.

Uses and Functions of the Forceps. — ^The main function
of the forceps is that of a tractor, which is by far the most im-
portant. Another function sometimes to be remembered is that
of a rotator, as, for example, when a straight forceps is applied to
the head in face presentation, with the idea of twisting the chin
forward. In a difficult forceps operation the instrument some-
times has the function of a lever ; the operator, swaying his arms
a little from side to side, pulls down first one side of the head
and then the other, in this way dislodging it from its impacted
position. Last of all, least frequently to be employed, and most
dangerous of all functions, the forceps may occasionally be
regarded as a compressor ; but the instrument is to be used for
this purpose only in cases where there is a choice between com-
pressing the head with the forceps and performing craniotomy,
by the former action extracting a child that is almost certainly
dead, but with one or two chances for life out of a hundred.

Indications for the Application of the Forceps. — ^The for-
ceps is an instrument designed mainly to reinforce the vis a tergo
in labor. The most important indication for the use of the in-
strument is found in actual and relative uterine or abdominal
inertia. The expulsive force may be relatively too weak if the
resistance is greater than normal ; hence the forceps is indicated
in contracted pelves, rigidity of the soft parts, and overgrowth
of the fetal body.

It may be necessary, in any case of head presentation in labor,
hastily to terminate the process. This is especially desirable
if conditions exist threatening the child's safety, as premature
detachment of the placenta, compression or prolapse of the cord,
prolonged pressure on the fetal head, feebleness and slow action
of the fetal heart, or sudden danger to the mother during the
second stage of labor, as in eclampsia.

There is a valuable indication of fetal condition during labor
in the action of the fetal heart. In case of serious disturbance
the heart-sounds first increase in rapidity, but soon become
slower. If they sink to 100 and remain at that rate for any
length of time, it is likely that the child will be bom dead, and
it is a good practical rule in obstetrics to apply the forceps and
to deliver the child rapidly whenever the fetal heart-sounds sink
to 100 and remain at that rate for a minute.

It may be desirable to save the mother the muscular exertion
necessary in the second stage of labor. This is particularly true
if labor is complicated by some adynamic disease, as phthisis,
typhoid fever, or pneumonia. It is most desirable to «»"'>•'' all

732 OBSTETRIC OPERATIONS,

muscular effort in the second stage of labor in valvular disease
of the heart.

A good rule of thumb to govern the obstetrical practitioner is
to apply the forceps in head presentations whenever the presenting
part remains stationary for two hours in the second stage of labor.

The forceps must not be applied until the head is engaged
in the superior strait. This rule, too, admits of some excep-
tions. It is rarely possible to fix the head in a contracted pelvis
with forceps, when the powers of nature are insufficient to attain
this end. It is also justifiable to apply the forceps to the head
loose above the superior strait in cases of placenta praevia
with the head presenting, and to bring it down as a tampon in
the pelvic canal.

The forceps must not be applied until the membranes have
been ruptured. This rule admits of no exception.

The forceps must not be used as tractors in impossible posi-
tions and presentations, as, for example, face presentations with
the chin posterior.

The forceps must not be used when the disproportion be-
tween the head and the pelvic canal is too great.

In selcctini^ an instrument, the author would recommend the
beginner, if he must restrict himself to a single forceps, to pur-

FORCEPS. 733

chase Simpson's. As soon as practicable, the Tamier axis-trac-
tion forceps should be added, and it is a great advantage to
possess, in addition to these two instruments, a light short
forceps for use at the pelvic outlet.

Preparation for the Operation. — The patient's consent, or the
consent of her husband or nearest relative, should always be
first secured. An anesthetic renders the operation less difficult,
and is to be recommended to beginners ; but if it is possible to
deliver the woman in a short time, — say, half an hour or under,
— and if the difficulty of extraction promises to be slight, the
anesthetic may be dispensed with.

The woman should be placed in the lithotomy position at the
edge of the bed, with her feet resting upon two chairs or sup-
ported by assistants. With the small forceps used at the pelvic
outlet the lateral position need not be altered. The whole forceps
should be immersed for from ten to fifteen minutes before use, in
a pitcherful of boiling water, which retains a sterilizing tempera-
ture for fifteen minutes after ceasing to boil actively, or, if it is
practicable, the instrument should be boiled for the same length
of time in a suitable instrument tray. Just before its insertion
the whole blade, both outer and inner surfaces, should be
smeared with carbolated vaselin.

The Application of the Forceps. — In using the Simpson forceps,
or any other with a non-detachable pin-lock, the left-hand blade
is always inserted first. The left blade lies upon the left-hand
side of the woman's pelvis, and is held in the left hand of the
operator. The right-hand blade of the forceps lies upon the
right-hand side of the pelvis when introduced in position on the
child's head, and is held in the right hand of the operator.
Assuming that the diagnosis of the presentation and of the
position of the presenting part has been made, and that the
vagina is rendered surgically clean, the successive steps in the
application of the forceps-blades may be summarized as follows :

Having introduced two fingers of the right hand into the
vagina, the left blade, grasped at the lock by the left hand as a
pen, is held perpendicularly to the woman's body, with the tip
of the blade opposite the vulva. The tip of the blade is inserted
in the vagina, and is pressed backward along the pelvic floor
toward the sacrum. The blade is then rotated outward on its
long axis to bring it in apposition with the posterior inclined plane
of the pelvis, and to escape the promontory of the sacrum : the
handle is depressed and the tip of the blade is thus elevated into
the uterine cavity, the fingers of the right hand in the vagina
guiding the blade and protecting the soft parts ; finally, the handle
is carried to the left side in order to engage the tip of the blade
over the curve of the child's head. The right-hand blade is in-
troduced in a similar manner, substituting the right for the left.

OBSTETRIC OPERATIONS,

^ -^f^

-V

ItVfr

Fig, 524.— liilroluwion of the left blade: lirsl step.

Fig. 515.— Introduciioii of tbe Icfi bltde : raOtloD oo (tt kmg axil.

738 OBSTETRIC OPERATIONS.

of course, in the foregoing description. As the blades lie a
their insertion it is impossible to lock them, for both of them hav<
ascended the posterior inclined plane of the pelvis, after I
rotated outward on their long axes. It is necessary to bring om
of them forward toward the region of the acetabulum, if the
head lies in the oblique position, before the blades wrll I
Obviously, the blade to be rotated forward within the pelvj
differs with the different position.*; of the pre.senting part,
left occipitn-nntcrior position of a vertex presentation the

l-'*g- 5J:

hand blade must be rotated forward, the left-hand blade lying as \
it was when first introduced. To rotate the right blade the j
handle is lightly supported by the fingers of the right hand, while
the first two fingers of the left hand are inserted under the hed
of the blade and gently pry it upward, outward, and tlicn inward.
If the operator finds it more convenient, he may reverse the hands.
If there is difficulty in locking the blades, a depression of both
handles toward the perineum often facilitates their conjunction.

The handles being appro.ximated and the blades joined, the
operator takes the grip upon the instrument shown in figure 530. ■

FORCEPS. 739

The forefinger of the right hand is kept extended against the
child's scalp to detect the first inclination on the part of the in-
strument to slip. Too great compression of the child's head
may be avoided by placing a folded towel between the handles,
and by using the slack of this towel to cover the shoulders of
the forceps-handles, the operator saves his fingers from exces-
sive fatigue and even bruising. The grip represented in figure
530, with pressure exerted downward, outward, and on the ends
of the handles upward, enables the operator to impose upon the
head a movement corresponding with the axis of the parturient
canal. If traction were made directly outward by pulling straight
upon the forceps-handles, much of the force would be lost by
dragging the head against the symphysis pubis.

In making traction, nature should be imitated as closely as
possible, the intervals between one's efforts corresponding to the
usual intervals between the pains, and the traction lasting for
about a minute. In the intervals of rest the blades should be
loosened, or even unlocked, to spare the fetal head from long-
continued and uninterrupted compression. The force should be
exerted by the muscles of the shoulders and arms. It is inad-
visable to throw the weight of the trunk upon the forceps and
it is absolutely inexcusable to utilize the muscles of the back and
legs, plus the weight of the body, by bracing the feet against *
the bed while pulling upon the forceps. The tractive force should
take a different direction as the head progresses along the par-
turient tract. When the forceps is at rest, the direction of the
handles is a good indication of the direction in which the next
traction should be made ; as the head descends the birth-canal
and appears at the vulvar orifice, distending the perineum, care
should be exercised to moderate the tractive force, otherwise the
head might be violently pulled out through, instead of over, the
perineum. When the degree of distention is reached shown in
figure 533, the grip on the forceps is changed. The handles are
seized in the right hand, as shown in figure 533, the operator
standing to one side of the patient. Instead, now, of making
traction, the forceps-handles with each pain are lifted and carried
up over the woman's abdomen, very little force being employed.
The outspread fingers and thumb of the left hand push the head
away from the perineum and guide it upward under the pubic
arch. When the pain passes off, the forceps-handles are allowed
to sink again. Finally, just before the head emerges, the grip on
the instrument is again changed so that the handles may be
almost laid on the woman's abdomen (Fig. 536). Used in this
way there is*no better safeguard for the integrity of the perineum
than the obstetric forceps.

742 OBSTETRIC OPERATIONS,

In the description of the application of the forceps it has
been assumed that the head is in a normal oblique position of a
vertex presentation and that the blades of the instrument are
applied to the sides of the fetal head, where they do the least
damage, and to the contour of which their cephalic curve has
been adjusted. It often happens, however, that the head occu-
pies an abnormal position, and the question arises whether the
forceps shall be applied at the sides of the maternal pelvis, where
the blades are not likely to injure the woman, or whether an
attempt must be made to adjust the blades to the sides of the
fetal head regardless of the additional risk to the mother. If,
for example, the head is transverse, as it usually is when detained
at the pelvic inlet in a contracted pelvis, one blade must lie
behind the symphysis and the other in front of the promontory
if they are to be placed at the sides of the fetal head. It is pos-
sible to so adjust them, if one possesses manual dexterity and is
skilled in the use of the forceps, but there is always a danger of
perforating the posterior uterine wall in the attempt. It is better
under these circumstances to place the blades obliquely, the
posterior behind the promontory of the occiput, the anterior in
front of the chin and mouth. By this adjustment the fetal head
is not likely to be so badly damaged as if the forceps were
applied directly over the face and the occiput, the anterior rota-
tion of the latter is facilitated, and the woman is subjected to no
extra risk.

It is not infrequently necessary to apply the forceps to the
head in a normally oblique position, but with the occiput directed
posteriorly. As the head descends, anterior rotation should
occur, and it is to be considered whether the grip of the instru-
ment will interfere with the rotary movement of the head upon
the pelvic floor. As a rule, it does not if the precaution is ob-
served to disengage the blades completely from each other by
unlocking them after each tractive effort. As soon as rotation
is accomplished, the forceps-blades lie over the occiput and the
face ; they must, therefore, be rotated into their appropriate
positions over the sides of the head, or, if it is difficult to do this,
they should be withdrawn and reinserted. To give a concrete
example : In a right occipitoposterior position of a vertex pres-
entation the two blades of the forceps are inserted along the
posterior walls of the pelvis to either side of the promontory' ;
the right blade is then rotated forward until it lies under the
right acetabulum. As the occiput rotates forward after encoun-
tering the resistance of the pelvic floor, the long anteroposterior
diameter of the head shifts from the right to the left oblique
diameter of the maternal pelvis, bringing the forceps-blades

FOKCEPS.

743

directly over the face and the occipital protuberance. The left
blade must, therefore, be rotated forward and the right backward,
or, if it is difficult to rotate the blades, they must be withdrawn
and reinserted as for a right occipi to -anterior position of a vertex
presentation.

If the occiput rotates into the hollow of the sacrum, the head
should be extracted from the vulvar orifice by the following
manceuver ; The forceps -handles are raised graduallyand inter-
mittently until almost the largest diameters of the head have
escaped ; then, instead of continuing the elevation, the left hand
firmly supports the head through the perineum and the forceps-
handles are depressed, turning the fetal face out from behind the
symphysis. In this way the perineum and pelvic floor are some-
what relieved of the tremendous strain imposed upon them in a
persistent posterior position of the
occiput. In applying the axis-
traction forceps, the bars are closed
against the blades, which are in-
serted in the ordinary manner.
After adju.sting the blades to the
sides of the child's head if possible.
or in an oblique diameter of the
pelvis, the blades are locked ; the
pin-lock of Tarnier's instrument is
screwed moderately tight ; the con-
necting bar between the handles is
thrown across, locked, and screwed
until the blades take a firm but not
too forcible grip on the fetal head.
The traction bars are then sprung

loose at their lower end and the handle is adjusted to them and
locked. Traction should be made in a line as nearly as possible
coinciding with the axis of the pelvic inlet — namely, backward
and downward. To do this even approximately the woman must
be placed upon a bed or table with her buttocks projecting well
beyond the edge and the axis-traction handle of the forceps must
be pulled downward and backward as far as possible. To pro-
tect the perineum from injury by the traction rods a Sims specu-
lum should be held in place during the tractive efforts. Between
the tractions the bar joining the handles should be unscrewed and
thrown out of place and the pin-lock should be unscrewed, thus
relieving the fetal head from continued pressure. As soon as the
fetal head has descended well into the pelvic cavity the axis-trac-
tion principle becomes unnecessary'. The handle should, therefore,
be removed, the bars fastened in their places by the blades, and

^'B- 5j8. — Aiis-imction forceps ; head nl llie superior slrniL

Fig. 539, — Axk-Uiiciiuii TorcepB ; head In the pelvic cavity.

EXTflACTIO.V OF THE BREECH.

745

the forcqjs used as an ordinary instrument or else withdrawn and
replaced by a Simpson forceps. Statistics as to \\\k. frequency of
forceps operations have neither interest nor value. They vary
enormously ill different clinics, in different classes of society, and
in the hands of different operators. The author is an advocate of
the frequent use of forceps, believing that more harm arises from
inordinate delay in labor to mother and infant than can be traced
to the use of the instrument in careful and skilful hands. The
mortality of a forceps operation, per se, should be iii/. The
most frightful damage, however, has been inflicted upon both
mother and child by the unskilful and careless use of the instru-
ment. The pelvic joints have been sprung apart by too forcible
traction ; the lower uterine segment with an undilatcd os has been
caught in the grip of the
blades and has been cut
through into the peritoneal
cavity ; the posterior wall of
the lower uterine segment has
been perforated by the tip of
one blade ; the child's scalp
has been cut and a forceps-
blade forced between its scalp
and the skull ; in an attempt
to apply forceps to the breech
in the mistaken notion that
it was the head, the tip of
a forceps-blade has torn the
perineum of a female infant
into the rectum ; the vaginal
vault has been perforated and
the vaginal walls deeply cut.
and frequently, indeed, is the
perineum torn, often into the
rectum, by a failure to elevate the handles sufficiently and to
moderate the tractive force as the head is extracted from the vulvar

EXTRACTION OF THE BREECH.

Breech labors arc normally slow and tedious. The indica-
tion.s for interference are: delay for more than twenty-four hours,
rapid and feeble pulse, signs of exhaustion, elevation of tempera-
ture in the mother, and abnormally slow fetal heart-sounds.

Methods of Extraction in the Order of their Efficiency. —
Manual Method. — Seizing a foot by passing a hand into the uterus,
extracting the leg up to the knee, thus decomposing the breech

Fig. 540. — To bring down a foot
wben it is Bgaiiisl tbe face, the knev may
be brnt by pressure in the iMiplilcal space
{modi tied (roia Farabeur and Vumier).

XTRACTIOl

presentation and affording a convenient handle to the fetus by
which to control the subsequent progress of labor, is the best of
all methods for extracting the breech, if it is practicable. I'inard's
suggestion to push one thigh outward and backward, thus flex-
ing the leg upon the thigh, occasionally makes it easier to <jrasp
the foot.

Another plan of manual extraction is to place the hand on
the infant's back, so that
the little and fore-fingers
hook over the crest of the
iiium, while the middle and
third fingers are extended
along the spine. This is
not so good. For both
mancL'Uvers the patient
must be anesthetized.

Forceps. — If the breech
is low in the pelvic canal,
and it is impossible to pass
the hand into the uterine
cavity to seize a foot, it
may be most convenient
to apply forceps over the
1 trochanters. By avoiding
compression of the han-
dles, and simply making
traction by hooking ones
fingers over the shoulders
of the instrument, the
breech may be extracted
readily, with no danger to
the child.

Extroctloti by Fillet. —
Each end of a strip of
bandage about two inches
wide may be passed be-
tween the thigh and the
abdomen and brought

down in front of the external genitalia. If drawn tight, the
loop of the bandage is in contact with the child's sacrum. A
very firm and convenient grip is thus taken upon the breech. The
fillet is very difficult to apply with the fingers. A fillet-carrier,
sliown in figure 544, makes the application much easier. An
anesthetic is required. This plan i.s-exccllent if the manual extrac-
tion is impossible, or if it is considered inadvisable to use forceps.

l-'ig. S4S.-

748 OBSTETRIC OPERATIONS,

Blunt Hook. — This instrument is passed between the thigh
and the abdomen. It is an extremely dangerous instrument for
the infant. It is very Hkely, indeed, to fracture the thigh or to
perforate the groin. Its use, therefore, is not recommended, and
is never resorted to by the author unless the child is dead.

THE ARTOTOAL DILATATION OF THE CERVICAL CANAL,

It is necessary to dilate the os artificially in cases of rigidit>' of
the cervix, or when it is desired to hasten labor for any purpose.
The OS may be dilated by Barnes' bags, by graduated bougies,
by the fingers, by pulling the head down with forceps, by taking
hold upon a foot or leg in a breech presentation, or by mul-
tiple incisions.

Hydrostatic Dilatation. — For this purpose rubber bags of a
fiddle shape and of graduated sizes are most convenient (see
Fig. 546). It is desirable to have the largest bag larger than
that ordinarily sold in the shops — that is, four sizes, the largest
one made specially. To insert one of these rubber bags, it is

Fig. 546. — Baraes' bag.

rolled upon itself, grasped in an Emmet curetting forceps, well
smeared with carbolized vaselin, and passed into the cervical
canal, so that the internal os corresponds with the constriction
around its middle. The tube is then attached to the rectal
nozle of a Davidson syringe, and the bag is distended with
water. It is well to test the capacity of each bag outside the
woman's body, to avoid overdistention and the danger of
bursting. When the bag is filled, the rubber tube attached to it
is clipped with a hemostat, which at the same time is made to
grip the bed-sheet, so that the water is held in the bag, and the
tube is supported firmly in order that it shall not drag the bag
out of the cervical canal. Each of the progressively larger bags
is inserted in the same manner, and allowed to remain in place
from fifteen minutes to an hour, according to the time at one's
disposal. As complete a dilatation of the os should be made
as possible, unless haste is necessary. The pockets made upon
the rubber bags are of very little use as an aid in their introduc-
tion, unless one inserts a heavy instrument, like a closed Emmet

ARTIFICIAL DILA TA TION OF THE CER VICAL CANAL, 749

curetment forceps, in them. The ordinary uterine sound, which
is often recommended for this purpose, is worthless.

Graduated Bougies. — The cervical canal may be dilated by
inserting graduated bougies from the size of a small lead-pencil
up to the size of one's wrist or forearm. This is a convenient
and effective method, but it requires a number of bougies which
are scarcely ever carried about by any obstetrician, and it
is, therefore, only available in a well-equipped obstetrical hos-
pital. In fifteen to twenty minutes by this plan the os may
be almost fully dilated or sufficiently at least to permit the ex-
traction of the child by the forceps if the head presents, or by
drawing down a leg in a breech presentation.

Fig. 547. — Hegar's dilators or bougies.

Manual Method. — ^The best manual methods for the dilata-
tion of the OS are illustrated in figure 548. In Harris' method
the fore-finger and thumb, and then the other fingers of the hand,
are successively inserted, the thumb and fingers being spread
apart as widely as possible. In Edgar's method the dilatation
is begun by branched dilators and is completed by the powerful
action of the first two fingers of both hands. By this means
very rapid dilatation of the os is possible, and the manual
method is recommended in cases of greatest haste, in which it
is only desired to secure enough dilatation to make the forcible
extraction of the child possible.

Forceps. — If the os is already about the size of a dollar,
and it becomes necessar>' to deliver the child rapidly, forceps
may be applied to the head and strong traction made. The
cervix will either stretch or tear, and it is thus possible to extract
a child in a very few minutes when there is urgent need for rapid
delivery.

Multiple Incisions. — This plan is an old one, but in its mod-
ern most effective form, of incisions through the cervix to the
vaginal vault, it was first proposed by Diihrssen.^ It is to be
recommended in cases in which there is need for the utmost
rapidity in the extraction of the child. If the head presents, it
is best to apply forceps to pull the head firmly down against

^ Wiener med. Presse, xxxi, '^'^.

750

OBSTETRIC OPBRATJOXS.

the cervix, and then with scissors, or a biunt pointed bistoury,
to cut the cervix in one, two, or as many as four places, until
the child can be dragged through the cervical canal. It is
necessary afterward to suture the incisions, which bleed pro-

Fig. 548. — Method of performing rapiti manual dilatation of the ob oleri: I,
Position of lingers in the beginning of manuiil or di^iul dilatBtion of (he cervU ulcri.
first position ; 3, »huwing limit of dilatation in Ibe Iml puulioD ; 3, second position ;
4, showing limit of dilaintion in Ihc second position ; 5, third position ; 6. limit of
liilatniioii In the third position ; 7. fourth position ; S. limit of dilaiation in the founb
position ; g, llflh position ; 10, sixth posillon (Harris).

fuscly for a time, at least. If the patJent should be in a serious
condition, it may be sufficient to place one suture in the upper
angle of each incision. This checks the hemorrhage sufficiently,
and promotes, occasionally, the entire repair of the injurj-.

ARTIFICIAL DILATATION OF THE CERVICAL CANAL. 75 1

□ further ouniuU

754 OBSTETRIC OPERATIONS,

VERSION.

Version may be defined as an operation or manoeuver to change
the position of the fetus /;/ utcro. The object of version is to
change a transverse into a longitudinal presentation, and to
change the presentation of one pole of the fetal ellipse into a
presentation of the opposite pole.

The changes in the position of the fetus are effected by four
methods — postural treatment of the mother, external manipu-
lation alone, internal manipulation alone, and a combination
of internal and external manipulations. As the child is brought
to present by the cephalic or pelvic presentation, the operation
is called version by the head or version by the breech If the
foot is seized and is extracted in the operation of version, the
operation is called podalic version.

The operation of version is an old one. Hippocrates speaks
of the difficulties encountered when a child lies crosswise in the
uterus. He compares it to an olive lying crosswise in a bottle
with a narrow neck. But Hippocrates believed that the infant
could only be delivered if it presented head first, and therefore,
in cross-positions of the fetus, if the effort to turn it with the
head toward the maternal pelvis did not succeed, embryotomy
was to be performed in the dreadful manner that was practised
in those days — tearing the child to pieces with sharp hooks.

Among the aboriginal tribes of Mexico a curious custom pre-
vailed in cases of difficult labor. A woman was seized by the feet,
suspended head downwards, and vigorously shaken. If the
dystocia was due to a transverse position of the fetus /;/ utcro, this
rough and unscientific treatment might, in a certain number of
cases, be effective, and it was no doubt in consequence of a few
successes that the custom had its origin.

In Japan, before the country had reached its present high
stage of civilization, it was customary to apply massage to the
abdomen of pregnant women, in order to straighten out a pos-
sibly faulty position of the fetal ellipse. In many primitive races
some form of version has been and is in vogue, handed down as
a custom of ancient origin.

Indications for Version. — The most important and the
most frequent indication for version is found in a transverse posi-
tion of the fetus /;/ utcro. In order to secure delivery, one or
the other of the poles of the fetal ellipse must be substituted for
the shoulder, which usually presents in a transverse^ position
of the fetus.

Contracted pelves are an indication for the performance of
version, when it is thought that the child's head can be brought

ARTIFICIAL DILATATION OF THE CERVICAL CANAL. 753

OBSTETRIC OPERATIONS.

VERSION.

Version may be defined as an operation or m
the position of tlie fetus in utcro. The objc
change a transverse into a longitudinal pn
change the presentation of one pole of the
presentation of the opposite pole.

The changes in the position of the fetus a
methods — postural treatment of the mother,
lation alone, internal manipulation alone, a
of internal and external manipulations. Astl
to present by the cephalic or pelvic presenta
is called version by the head or version by tl
foot is seized and is extracted in the operati
operation is called podalic version.

The operation of version is an old one. I
of the difficulties encountered when a child Ii<
uterus. He compares it to an olive lying cr
with a narrow neck. But Hippocrates believ
could only be delivered if it presented head f
in cross-positions of the fetus, if the effort t
head toward the maternal pelvis did not sue
was to be performed in the dreadful manner
in those days — tearing the child to pieces witl

Among the aboriginal tribes of Mexico a c
vailed in cases of difficult labor. A woman wa
suspended head downwards, and vigorously
dystocia was due to a transverse position of the
rough and unscientific treatment might, in a ■
cases, be effective, and it was no doubt in cor
successes that the custom had its origin.

In Japan, before the country had reachct
stage of civilization, it was customary to app
abdomen of pregnant women, in order to str
sibly faulty position of the fetal ellipse. In m;
some form of version has been and is in vogU'
a custom of ancient origin.

Indications for Version. — The most ii
most frequent indication for version is found ir
tion of the fetus ill utcro. In order to secur
the other i^f the poles of the fetal cllip.se musi
the shoulder, which usually presents in a t
of the fetu.s.

Contracted pelves are an indication for tl
version, when it is thought that the child's he

VERSION, 755

through the contracted pelvic canal more easily with the small end
of the wedge coming first than last. If it is necessary to deliver
the mother rapidly, in cases of sudden danger, when the head is
presenting but not engaged, as in eclampsia, premature detach-
ment of the placenta, rupture of the uterus, embolism, and death
of the mother, podalic version furnishes the most rapid means
of delivery. In malpositions of the head, as presentation of the
ear, of one parietal bone, of a brow or face, it is better to sub-
stitute for the unfavorable presentation of the head the more
favorable presentation of the breech, which is secured by podalic
version, or by version by the breech. In placenta praevia, if the
head is presenting, version is indicated, in order to bring down
the breech as an intrapelvic tampon upon the bleeding placental
side. In prolapse of the umbiHcal cord, version is indicated if
the cord can not be returned into the uterine cavity and kept
there.

Before undertaking the operation of version, it is quite as
important to realize the contraindications to the operation as
it is to recognize the indications. Version is positively contra-
indicated if the presenting part is firmly engaged in the pelvic
canal and has passed out of the external os ; also, if the con-
traction-ring is so high that a rupture of the lower uterine seg-
ment is threatened if version is attempted.

While these are the only positive contraindications to the
operation, the following conditions may make it difficult, dan-
gerous, or quite impossible : an undilated and undilatable
vagina ; a similar condition of the cervix.

These obstructions may usually be overcome under anesthesia,
or they may be insuperable obstacles to the performance of
version.

It may be impossible to effect an entrance into the uterus, as
when the liquor amnii has long been drained away and the
uterus is firmly contracted, when the uterus is permanently
contracted in what is called a tetanic spasm, when there is
some obstruction on the part of the fetus, as hydrocephalus and
spina bifida with a large meningocele, or if the presenting part is
pressed firmly upon the superior strait. The last-named difficulties
may be obviated by placing the woman in the knee-chest posture.

Prolapse of the arm, at one time considered a serious ob-
stacle to the performance of version, is no longer so. The phy-
sician's hand can readily pass by the arm, and indeed it is some-
times an advantage to pull the arm out of the external os before
attempting version.

It may be impossible to bring the feet down in podalic version
after they are grasped. This difficulty may be overcome by

applying a fillet to the loot, and, while traction is made

it, the other hand of the physician in the vagina pushes the"

shoulder upward and in the direction of the child's head.

Certain conditions may interibre, also, with the manipulation
of tlie external hand in combined and in podalic version, as an _
excessive amount of fal in the abdominal wall, or convulsions ii
eclampsia, t-'pilepsy, chorea, and hysteria. On the other handj
the conditions most favorable for the operation arc : a uterus d
tended by liquor amnii, a dilated os, a uterine muscle that is no^
irritable, abdominal muscles that are flexible and thin, and I
cervix well dilated or easily dilatable.

Postural Version — In this method the woman is put in il

fercnt positions to influence the position of the child i» .
the force of gravity. For e.samplo, if the brow should presc
the woman should be turned on that side toward which the (ctti
back looks, so that the breech may drop to that side, and thM
bring the vertex to the center of the superior strait; or, if t' '
head should be tightly fi.xed in the superior strait, the wom
may be turned on that side toward which the face looks, in ord
to promote the fle.vion of the child's head, and thus favor a col
version of the brow presentation into one of the vertex.

This is a simple, safe, and easy means of performing vcrsiol
if it is practicable. It is usually, however, unsuccessful, and tbl
physician must be prepared to resort to other plans when 1

VERSION. 757

Version by External Manipulation. — This method may be
used before labor to convert a breech presentation into a presen-
tation of the head, or to correct a transverse presentation.
When the child has been brought into the position desired, by a
series of stroking movements, pads and a binder should be ap-
plied to prevent the return of the child to its original position.
This method, while successful in a fair proportion of cases, requires
often an expert's skill ; a diagnosis of the position before labor
has begun ; the preservation of the membranes ; thin, flexible
uterine and abdominal walls, and non-irritable muscles.

Combined Version. — ^This method was first proposed by
Busch, D'Outrepont, and by Dr. Wright, of Cincinnati, and was
later advocated by Braxton Hicks, of London. The operation is
performed as follows : The patient is placed in the lithotomy
position and anesthetized. Externally, the hand nearest the fetal
part to be acted upon by external manipulation seizes this part
through the abdominal walls, the operator being seated facing the
vulva. The internal hand pushes the presenting part up and
to that side opposite the fetal part acted upon by the external
hand. For example, in a shoulder presentation, with the face
of the child turned forward and the head in the right iliac
fossa, the physician seizes the head with his left hand, inserts the
right hand in the vagina, and with two fingers of this hand
passed into the uterine cavity pushes the child's left shoulder
upward and toward the mother's left-hand side, while the head
by external manipulation '\s pulled downward and toward the
median line. In all shoulder presentations, version by the head
should be preferred to version by the breech in the combined
method, for this presentation is more favorable to the child, and
the head is more readily brought to present at the superior strait,
making the version easier and quicker of performance than if
the breech were brought down.

Podalic Version. — This operation was known in the time of
the Roman Empire, but was lost sight of until Ambrose Pare and
his students revived it in the sixteenth century. The operation
is performed as follows : Relaxation of the uterus and of the ab-
dominal muscles is secured by an anesthetic. The lowest pos-
sible position of the fetal feet is secured by turning the mother
on that side toward which the feet point. That hand which,
midway between pronation and supination, as the operator faces
the woman's vulva, corresponds with its palmar surface to the
abdomen of the child is inserted, in an aseptic condition, into the
uterine cavity, until it meets the anterior foot. This foot is
grasped by the first two fingers and the thumb, and is then ex-
tracted until the knee appears at the vulva.

ill

758

OBSTETRIC OPERATIONS.

Fig. 556. — D'Outrepont's meihod of combined

I^'S- 553.— Combined version. Wrighfi

r£A'S/OA-.

759

The advantages of resting content with the anterior foot, and
of drawing upon it alone without seeking for the other, are these :
A further entrance into the uterus is unnecessary. It is easier
to hold one foot than two. The other leg is folded up upon the
abdomen, and thus secures a more thorough dilatation of the
cervical canal. Finally, by pulling upon the anterior foot one
is more Ukely to secure a sac ro -anterior position of the breech.
While making traction upon the foot, the version of the child is
facilitated by external manipulation of the head (Kig. 562). It
is occasionally easier to seize a leg or the knee than the foot
(Figs. 563, 564). In such a case time need not be wasted seek-

ing for the foot. Combined version by the breech may precede
or replace podalic version with great advantage, as first pointed
out by Braxton Hicks, obviating the necessity of introducing the
hand into the uterine cavity and enabling the operator easily to
seize the knee or foot after it is brought near or into the supe-
rior strait.

As soon as the knee is bom, the operation of podalic version
is finished, and, unless there is some indication for immediate
delivery, the anesthetic should be removed, the patient should
be turned upon her back, and should be allowed to expel the
child spontaneously until the umbilicus appears in view. This
delay secures a more thorough dilatation of the cervical canal,

TOO OBSTETRIC OPERA TIO.VS.

and produces a paretic condition of the circular muscle of :r.v
cervix. The advantages of this condition of the cer\-i.\ art
obvious when it comes to tlie extraction oi the atter<'-'ni!n^
K-,i*.i With an undilated cervical canal and a ri^d ccnka!
T::::-*v-le. the ni-ck is likely to be grasjicd in so firm a lioid \\::a
,<.'. v'Ti'rts to extract the head are unavailing until the chilii :?
isphyxL-itev!. In rare cases rapid extraction maj- be indicated

, .\ri ;^-:"ed upi^n lorcibly. as shown ir. ti-;-
> ■,: > :i,>dy beinj; sIi|1[x.•r^-, should usuaily

\\ rji-;: the child is bom to tlte umbilicus
^r.i :> ^real, and delay in the extraoiiv.
; ■.^-■:-: means an asphyxia so deep that i

iv. 7i.\:ved. From this moment, there-

VERSION. 761

fore, the attendant niiist put forth every eflbrt possible to secure
the most rapid deUvfrj- of the infant. This is effected bj- the

following methods : The arms, if extended alongside of the
child's head, as they usually are after version, must be extracted
in the following manner ; locate the posterior arm by the

763 OBSTETRIC OPERATIONS.

position of the trunk and shoulders. To deliver the right arm,
grasp the legs with the left hand, the middle finger above
the internal malleoli, the index and middle fingers above the
external malleoli. Raise the child's body upward and outward
over the mother's right thigh. This movement should be suffi-
ciently forcible to bring the right shoulder well down in the
pelvis. The first two fingers of the right hand, entering the
vagina in contact with the right scapula, are passed along the
posterior surface of the arm beyond the elbow, when the arm
and forearm are pushed in front of the child's face as though the
elbow-joint did not exist. The fingers are now hooked in the

Fig. S66-

ing bclh

elbow-joint and pulled directly downward until the elbow appears
at the vulva, tlie forearm being flexed by this movement upon the
arm. The forearm is then easily delivered by cxtcn.sion. The
left arm is hroujjht down and delivered in the same manner, sub-
.stituting. of course, ri^jht for left. The right hand grasps the
child's feet and lifts them over the mother's left thigh, at the siuiie
time rotating them 011 their lon^' axes so as to twist the botly and
thii.s bring the anterior arm into the posterior ])ortion of the jx-lvis.
The fingers of the left hand are inserted into the vagina past the
elbow-joint. The arm is swept forward over the face, as though
it were a single [)iecc without the elbow-joint. The elbow is
then flexed. ]>ullcd downward, and the forearm extended at the
vulvar orifice. Should the shoulders occupy a transverse posi-
tion, either arm may be brought down and delivered first. After

I'ESS/O.V. 763

dtlivering the arms, tlie head may be extracted by one of the
following methods, given in the order of tlicir efficiency and
safety :

Wiegand's Method. — In this method tlie first three fingers of
the supiiiated hand are inserted into the vagina, that hand being
employed whose palm corresponds to the abdomen of the child.
Over the forearm of this hand the child's body rests astride.
The index-finger of the hand in the vagina is inserted in liie
child's mouth, care being exercised to avoid the eye-sockets.

of brim [Dickinson).

Sufficient traction is exerted upon the lower jaw to secure and
maintain flexion of the head. The disengaged hand now locates
the head through the abdominal wall above the pubes, and
delivery is accomplished by suprapubic pressure in the axis of
the parturient canal, and by the elevation of the child's body
toward the mother's abdomen.

Mauriceau's Method. — One hand is inserted in the vagina, as
described above, and one finger is placed in the child's mouth.
The other hand is passed along the child'-s back until the middle
finger rests upun the occipital protuberance. The inde.x- and

764 OBSTETRIC OPERATIONS.

ring-fingers are flexed over the clavicles, and traction is made by
both hands at once, the force upon the jaw and the pressure
upon the occipital protuberance keeping the head well flexed.

Fig. 568. — Combined

upon mouth and shoulders (Mauriceau).

Fig- 5&9- — Second -lep of the M;

while the traction u])on tlio shoulders extracts tlic head in the
dircctioi) of the parturient canal. As the head descends upon
tiie pelvic floor, the child's body is carried upward toward the
mother's abdomen. Pro])orly directed suprapubic pressure by

r£XS/OM 765

an assistant increases the efficiency of this method, and makes it,
indeed, the most effective of all methods in extracting the after-
coming head.

Prague Method.^ — -The child's ankies are grasped with the
right hand pronatcd, the middle finger being placed between the
legs just above the internal malleoli, the index- and ring-fingers
above the external malleoli. The index -finger of the left hand
is flexed over one clavicle, and the remaining fingers of the same
hand over the other clavicle. Traction directly downward is
now made with both hands until the perineum is well distended.

The right hand then loosens its hold upon the ankles, and again
grasps them as described above, but approaching them at their
anterior surface. The child's feet are now in contact witJi the
back of the right hand. The feet are then raised by a circular
movement toward the mother's abdomen, while the left hand as
originally placed is used as a fulcrum, around which the head
moves until it is finally forced out of the parturient outlet by a
lever-like movement on the part of tlie child's body.

Forceps. — An assi.stant should raise the child's body, sup-
porting its arms and legs, and thus keeping them out of the way
of the operator, who rapidly applies the blades to the .sides of the

766 OBSTETRIC OPERATIOXS.

child's head. Ti-actioii is made in the direction of the axis cX^
the parturient canal, and the head is finally delivered by lifting!
the handles of the forceps, the disengaged hand protecting 1
perineum as much as possible.

De venter's 'Method. — The child's body is seized as in thefl
Prague nicthntl, but the arms arc still alongside the child's heaffl^

and need not be extracted first. The body is pulled directly
downward toward the ground, until the shoulders descend and
press upon the pelvic floor. The child's body is then carried
downward and backward under the woman's buttocks, the head
being rolled out of the parturient outlet between the arms, which
easily follow after. To do this the woman's buttock.s must pro-
ject well beyond the edge of the bed, and the child must be *

EMBR } O TOM y. 767

carried well under them. The operation is only possible under
the most favorable conditions, and is not always to be relied upon.
It has, however, the merits of simplicity and rapidity.

EMBRYOTOMY.

Embryotomy is a mutilating operation upon the fetus. The
term is generic, and includes the following operations: Craniotomy,
decapitation, evisceration, and amputation of the extremities.

Craniotomy. — In this operation the child's head is perforated,
the contents evacuated, and the head thus diminished in size.
The forcible extraction of the evacuated head is often also a part
of the operation. The operation may be indicated upon a dead
or upon a living child. In the former case the indications for
the operation may be comparatively trivial. If the mother can
be saved any additional risk or suffering by the rapid delivery of
the mutilated child, craniotomy is not only justifiable, but advis-
able. In case of prolapse of the umbilical cord, with a con-
tracted pelvis, the commonest condition that calls for craniotomy
upon a dead infant, it is far better to open the head and to deliver
the child easily with a cranioclast, than to apply the forceps to the
head at the superior strait and to subject the mother to the
delay, pain, and danger of a prolonged forceps operation, when
nothing is to be gained by it.

Craniotomy upon the living child is only justifiable in excep-
tional circumstances. To condemn this operation, however,
unreservedly and without exception is a mistake. In cases of
difficult labor, if the pelvis is contracted or the child over-
grown, and the physician must make a choice between Cesa-
rean section, symphysiotomy, or craniotomy, if he has no skill
in surgical work and is unable to procure expert assistance, it is
better, unquestionably, to sacrifice the child for the mother's sake,
^ rather than to attempt a serious surgical operation, amid un-
favorable surroundings, and performed by an unskilful operator
whose mortality must be very great.

Every attempt must be made to avoid the destruction of a
living child, of course ; and if the operator feels himself pos-
sessed of sufficient skill to attempt the more serious operations
of Cesarean section and symphysiotomy with fair prosf)ect of
success, or if he can summon to his aid an expert obstetric or
abdominal surgeon, he should not think of performing crani-
otomy upon the living child. But under certain circumstances
craniotomy upon a living infant is a justifiable operation, and
one not to be unreservedly condemned.

768 OBSTKTfUC OPERATIOSS.

The Instruments for the Operation — Embryotomy is ttu

oldest operation of obstetrics and the instruments for perfor
It would make an interesting historical collection. The sharp
iiook or crotchet in its numerous forms had a place in the obslet
rician's armamentarium for many centuries. At the present c
the operator may need for craniotomy a perforator, a head scizer

Fig. S 73- — A, Sharii bookcrcrotdiel ; B, Jlamielocque's cqjlialotiibe.

L^,

or cranioclast, and a head crusher in its various forms of cephalo
tribe, basiotribe, or basilyst.

Perforators. — The best perforator is Blot's, Smellie's perform
tor or Hodge's scissors answer the purpose well enough, and u
the absence of an instrument specially devised for the purpo:
any long, sharp-pointed scissors serves admirably.

Head Selzers or Crsnloclasts. — This in.strument was ini
by Sir James Y. Simpson. It has been much improved by C

EMBKVOTO.UY.

;69

' Fig. s:;.— Iiloi'spfrf^i:

fig. 576.— Oldest Ultra of otanioclast.

OBSTETRIC OPERATIONS.

>ig. 581, — Tacnier's basiotribe.

§3 j^ JW~»MBBM»J

EMBRYOTOMY.

771

Braun and the author has added to the latter instrument a pelvic
curve, which facihtates its application at the superior strait. The
cranioclast is made witli two blades : one for insertion inside, the
other outside, the skull. The handles are provided with a screw
and nut to bring tliem close together, so as to give the blades a
powerful grip upon the skull.

Head Crushers or Cephalotribes. — The cephalotribe is the in-
vention of the younger Baudelocque. It is simply a heavy,
powerful forceps with the handles screwed together so as forci-
bly to compress the skull between the blades. The best cephalo-
tribe is Tarnier's basiotribf, which combines a perforator and a
powerful head crusher.

Other modern instruments for the extraction of the mutilated

F«. 584-

of (he insinim
ihe fonlanel (Ukki

head are Simpson's basilyst and Van Huevel's laminator. The
latter is designed to saw off the face and the occipital protuber-
ance. A wire ecraseur answers the purpose perfectly Hell, as
was shown by Barnes. In addition to the.se instruments, the
operator needs a heavy \'olsella forceps and a large metal catheter
to break up the brain and to wash it out of the skull.

.The technlc ol the operation is as follows ; The woman
should be anesthetized not so much because the operation is
painful or prolonged, but to .spare her the sight of her mutilated
infant. The patient is placed in the lithotomy position, and
brought well to the edge of the bed or table on which she lies.

772 OBSTETRIC OPERATIONS.

The vagina is scrubbed with tincture of green soap and hot
water on pledgets of cotton. Following this, a douche of
bichlorid solution, i : 4000, is given. The child's scalp is then
seized by a strong volsella forceps, which is handed to an
assistant, who pulls upon the instrument firmly, so as to fix the
head at the superior strait. The operator then inserts two
fingers of his left hand, made aseptic, and feels for a suture or a
fontanel. The perforator is then inserted into the vagina, along
the palmar surfaces of the fingers, and is plunged into the skull

Fig. 585. — The head after delivery by ihi

at a point upon which the finger-tips rest — that is, through a
fontanel or a suture. Wiien it has entered the skull the per-
forator is twisted about in all directions, in order to break up the
brain and is also opened in several different directions to enlarge
the opening in the skull. The large catheter is next inserted and
attached to a David-son syringe. A column of water is injected
into the cranial cavity, to wash out the remaining brain-substance.
Next, if it is necessary, the size of the emptied head may be
reducL-il with a cephalotribe. This is only called for in case of

EMBRYOTOAfY.

771

extreme pelvic contraction, or in the presence of some pelvic
tumor seriously diminishing the capacity' of the pelvic canal. In
the vast majority of cases a cranioclast should be used instead
of the cephalotribe. The internal branch of this instrument is
inserted within the skull. The outer branch is next introduced in
the same manner that one would insert a blade of the forceps.
The two branches are then locked, and the bandies are screwed
firmly together, care being taken that the internal branch isinserted
deeply within the cranial cavity, so that it shall get a firm grasp
upon the skull. The child is now extracted in the same manner
that one would extract the head with the forceps, except that
the tractive efforts are made uninterruptedly and with greater

force. In certain cases it is sufficient simply to perforate the
skull. This applies particularly to cases of hydrocephalus. The
head being evacuated, the forces of nature are sufficient to in-
sure the child's delivery. If it is necessary to perforate the after-
coming head, the perforator may be inserted behind the ear, in
the lambdoid suture, under the chin, through the roof of the
mouth, or. possibly, through the foramen magnum, In a case
of hydrocephalus with breech presentation, should there be great
difficulty in reaching the after-coming head, it is possible to
evacuate the fluid by perforating the spinal column and passing
a catheter through the spinal canal into the cranium.

Decapitation. — The chief indication for decapitation is an
impacted shoulder presentation, in which it is impossible to do

774 OBSTETRIC OPERATW.VS.

version, either on account of the inability to move the child i
because of the risk of ruptured uterus owing to the cnormousi
distended lower uterine segment. The instruments needed fi

fig- 587— Bfami% hook.

this operation are a Braun hook or a Ramsbotham sharp hoi
The former is fastened firmly over the child's neck, when witll
two or three sharp tiirn.s of the wrist the neck is broken, and the
soft structures may be pulled
through with the hook ; '
or may be severed with sci
sors. The Ramsbotham kni
edged liook is passed over tht
neck, and by a rocking motioi
is made to cut through all the
tissues of the neck.

In the absence of specialld
devised instruments
purpose, a string may be »
ried over the neck and the?
child decapitated by a sawing
movement with the string, the
vagina and perineum being
protected by a Sims speculum
Amputation and eviscer
tion are very rarely indicate
Some forms of monstrosid^
may possibly require
operations. A long-handl^
scissors is the best instruma
for the purpose.

SYMPHYSEOTOMY.

The operation of symphyse-i

Fig. 5S8.— Decnpilolion wiili Braun's otomy is a division of the publtf

Uuok (Uitiiiosou). joint, allowing a diastasis of J

the bones during labor,

child being extracted through the natural passage. The operaJ

tion was suggested for the first time in 1598, and was performed'*

S YMPI/YSE 0 TOMY. 775

for the first time on a living woman in 1777 by Sigault in
Paris. For a time symphyseotomy was in high favor, but the
mortality that followed it, and the accidents which frequently
marred its success, prejudiced the medical world against it, and
it gradually died out. In 1866 the operation was revived in Italy,
and from that time to 1886 it was performed 7 1 times with a death-
rate of 25 per cent. The success achieved in the latter years
of this period attracted the attention of the Parisian school of
obstetricians. The operation was revived in its original home,
and this revival was followed rapidly by its adoption throughout
the civilized world. In the following three years there were 74
operations in the United States, with 10 maternal deaths and
1 8 infantile deaths. The mortality for America is about 1 2 per
cent., but certain operators abroad have had as many as 20 cases
in succession without a fatal result, and in Italy 54 symphy-
seotomies have been performed with but 2 deaths. Even the
best records for Cesarean section do not equal this, and, taking
into consideration the statistics of both operations throughout
the civilized world, it may be said that Cesarean section is about
twice as dangerous to the mother as is symphyseotomy in the
hands of a surgeon not specially trained. The expert abdominal
surgeon, however, with a thorough aseptic technic should have
a very low, and about an equal, mortality in both operations.

An objection long urged against symphyseotomy, and one that
retarded its general adoption, was that little space is gained by the
separation of the pubic bones. But a careful study of the subject
on the living woman and on cadavera has shown that the separa-
tion of the symphysis up to 7 cm. (2 3^ in.) secures an increase in
the anteroposterior, the transverse, and the diagonal diameters of
the pelvis of 1.4 cm. (0.55 in.), 3.1 cm. (1.22 in.), and 3.5 cm.
(1.4 in.), respectively. Clinical observation, moreover, has dem-
onstrated its utility in pelves with a conjugate above 7 cm. (2^
in.). This, in my opinion, should be the lowest limit for the
operation. It is possible to achieve success with a conjugate
as low as 6.5 cm. (2.56 in.), but in a pelvis so badly contracted
.symphyseotomy is more dangerous than Cesarean section, and
it is possible that after the symphysis is severed it may be found
necessary to deliver the child by craniotomy.

The Indications for Symphyseotomy. — This operation should be
the alternative of version in flat, contracted pelves. The woman
with a conjugate diameter over seven centimeters should be al-
lowed to remain in active labor twenty-four hours. If at the end
of that time the head is not engaged, axis-traction forceps should
be applied and an attempt made with the instrument to engage
the head. If after some twenty minutes of intermittent traction
with justifiable force the head is not engaged, a choice must

776

OBSTETRIC OPERATIONS.

be made between version and symphyseotomy. The former is
ahnost always practicable with a conjugate over seven centi-
meters, but the mortality of the infants is about thirty-three per
cent. The latter practically insures a living child but is distinctly
dangerous to the mother, especially if the operation must be
performed in a private house, and in an emergency. The case
should be laid before the woman or her husband, who should
certainly have some voice in the decision. The only situations
in practice in which version need not be considered as an alter-
native to symphyseotomy are the firm impaction of the present-
ing part in the superior strait, and labors obstructed by a gener-
ally equally contracted pelvis and by a kyphotic pelvis.

The Technic of the Operation. — This differs as one prefers the
French or the Italian method. The latter, to my mind, is to be
preferred. It is quite as easy as the direct incision, and it has

Fig. 589. — Galbiati's knife for cutting the symphysis.

Fig. 590. — Author's knife for cutting tlie subpubic hgament.

the great advantages that the wound is more readily kept from
infection after delivery and that injuries to the urethra and blad-
der are more surely avoided. To perform the operation accord-
ing to the Italian plan the technic is as follows :

The abdomen and pubic region should be cleansed as though
for an abdominal section. An incision is made just above the
symphysis, about an inch long, through the skin, fat, and super-
ficial fascia. The attachment of the recti muscles to the pubic
bones is then severed by a transverse cut just sufficient to
admit the fore-finger behind the symphysis. The fore-finger of
the left hand is passed behind the symphysis and hooked
under it, while an assistant inserts a metal catheter in the
woman's urethra, holding it down and a little to one side,
usually the woman's right. The curved or sickle-shaped knife
of Galbiati is then seized firmly in the right hand and passed
along the indcx-fingcr of the left hand until it glides under the

SYMPHYSEOTOMY.

777

symphysis. With an upward and forward rocking movement of
the knife the synipliysis is divided. It will almost invariably
be found that this incision has failed to divide the subpubic
ligament. To cut thi.s, a smaller curved knife is inserted into
the wound and passed under the ligament, which is then severed,
from below upward, without difficulty. At this point in the
operation there is usually a good deal of hemorrhage, which

Fig- S9I-— Suhcuu

.pl»«=.

occasionally is most alarming. It can be checked at once, how-
ever, by packing the wound firmly with a strip of iodoform
gauze. During this part of the operation two assistants hold
the woman's thighs equally flexed and at an equal distance apart.
Each assistant should also support the pelvis by firm pressure
with a hand upon the trochanters. If the child's head is pre-
senting, axis-traction forceps should be applied to it, and the
head slowly and interruptedly extracted along the parturient
canal, at each tractive effort the assistants being warned to exert
firm lateral pressure upon the pelvis to prevent too great separa-
tion of the pubic bones, which would endanger the integrity of the
sacro-iliac joints. As soon as the child is born, the knees of
the woman -flre brought together and the thighs are somewhat

778

OBSTETRIC OPERATIONS.

extended. The operator then cleanses his hands again, removes
the gauze packing from the suprapubic wound, inserts a finger
behinti the symphysis to see that the bladder is not nipped
between the pubic bones, and then sews together the abdominal
wound with three or four silkworm-gut sutures. It is quite
unnecessary to suture the pubic bones or the symphysis,
dressing of aseptic gauze, cotton, and adhesive strips is applie

FiC' 59^> — French method of ptrf'

to the wound. A firm binder is placed about the hips, ani
the woman is put in bed straight upon her back, upon an even'
mattress, which should be firm enough not to allow of sagging:
where the woman lies upon it. It is an advantage to support'
the sides of the pelvis with sand-bags during the woman's con
valescence. They should be placed directly alongside the hips,
extending at least to the knees.

The after-care of a symphyseotomy is exceedingly trouble-
some. The patient must usually be catheterized, and much care
must be excrci.sed to keep the vulva and the surrounding regions
clean. This is best done by slipping a bed-pan under the
woman's buttocks and rinsing off the external genitalia tw
three times a day with a weak solution of bichlorid of mercury.
A slip sheet should be placed over the sand-bags ami under
woman's buttocks. The knees must be kept bound together;]

CESAREAN SECTION. 779

and the woman must lie quietly upon her back for at least three
weeks. If it becomes necessary to disinfect the parturient canal
during puerperal convalescence, the legs should be raised straight
in the air, without separating them or without bending the knees.
A bed-pan is then slipped under the woman's buttocks, and the
physician can carry out curetment and intra-uterine douching
with comparative convenience.

In the French method of performing symphyseotomy an
incision is made directly over the joint, which is then cut with an
ordinary scalpel.

Ayers ^ advocates a subcutaneous section of the joint through
a small incision under the clitoris, the joint being cut with a probe-
pointed bistoury from above downward and from before backward.

It is asserted that synostosis of the symphysis occasionally
complicates the operation. I suspect that in the majority of
such cases the operator has missed the joint. In view of this
possibility, however, a chain or a metacarpal saw should be
among the instruments prepared for the operation.

CESAREAN SECTION. »

When the escape of the child by the natural passage is impos-
sible, it may be delivered by an abdominal and uterine incision.
Cesarean section may be performed ante- and postmortem.

Postmortem Cesarean Section. — If a pregnant woman near
term dies suddenly, the abdomen and uterus may be cut open as
quickly as possible, in order to deliver a living infant. It is said
that the child has been extracted alive twenty minutes, three-
quarters of an hour, and even two hours after the death of the
mother, although it is almost inconceivable that this should be
so. The child's death usually is synchronous with that of the
mother, or follows a few moments afterward. In my opinion
rapid version and extraction preceded by forcible dilatation of the
cervix is a preferable method of delivery in a woman who has
died suddenly during pregnancy, and, if possible, the operation
should be completed before death has actually occurred. The tis-
sues of the dying woman offer no resistance to the forcible dilata-
tion of the cervix, and the extraction of the child can be effected,
as a rule, quite as quickly by version as by Cesarean section.

Cesarean Section upon tlie Living Woman. — The first recorded
Cesarean section upon a living subject was performed in Europe
in the year i6io^ ; but the operation is probably a much older

* "American Journal of Obstetrics," vol. xxxvi, p. i.

' The name is not derived from Csesar, but from the Latin description of the
operation, Caso matris titer o.

* By Trautmann in Wittenberg. The patient lived twenty-five days.

780 OBSTETRIC OPERATIONS,

one, and was in all likelihood known in certain primitive tribes
and nations in remote antiquity. Until quite recent times the
mortality of Cesarean section wae so high that the operation was
avoided at any cost. Among the procedures devised to avoid it was
laparo-elytrotomyy an operation that is no longer justifiable. A
few years ago in England the death-rate was more than 99 per
cent. Throughout the civilized world the mortality was at least
50 per cent. With the improvement in the technic of abdominal
surgery, and with the perfection of asepsis in such surgery, the
statistics of Cesarean section have steadily improved, until at the
present time it has been possible to collect 68 consecutive cases
with a mortality of 5.8 per cent., and 27 cases with a mortality
of 3.7 per cent.^ Under favorable circumstances and in the
hands of skilful operators, the mortality of Cesarean section may
be very low, perhaps below 5 per cent.; but in general practice
the mortality of the operation remains high, and will probably
continue so. In America the mortality, according to Harris'
statistics, ranges from 30 to 40 per cent.

Varieties of tlie Cesarean Section. — In 1 876 Porro ^ modified
the operation by successfully performing, in addition to the celio-
hysterotomy, a hysterectomy — that is, a removal of the uterus.
The stump was fixed in the abdominal wound, and treated extra-
peritoneally. The improvement introduced by Porro reduced
the mortality one-half by the prevention of leakage through the
uterine wound into the abdominal cavity.

The next improvement in the technic was introduced by
Miillcr, who advocated a long abdominal incision through w^hich
the womb was delivered before it was incised. This prevented
the soiling of the peritoneal cavity by liquor amnii and blood.
Miiller also advocated the application of an Esmarch tube around
the cervix and broad ligaments to control hemorrhage, but this
is a bad plan, as it predisposes to postpartum bleeding from
relaxation of the womb, and is never really necessary'. No con-
striction of the cervix at all is required if the operation is done
with sufficient rapidity.

The most important modification of Cesarean section in recent
times — or, at least, the modification that has attracted the most
attention, and has apparently done most to improve the mor-
tality of Cesarean section — was that introduced by Sanger. ^
Sanger was the first to propose the careful and accurate closure
of the uterine wound by a double layer of sutures. At first it

^ Leopold, ** Ueher loo Sectiones Cesarecu," ** Archiv f. Gyn.," Bd. Ivi,

2 The amputation of the uterus after a Cesarean section was first proposed by
Michaelis in 1809, and first carried out with a fatal result byStorer, of Boston, in lS6$.

3 ♦* Archiv f. Gyn.," Bd. xix.

CESAREAN SECTION. 78 1

was thought necessary to make a peritoneal flap by exsecting a
portion of the uterine muscle below the peritoneum. But it was
soon recognized that this was unnecessary, and the present prac-
tice is to use simply a deep and superficial layer of sutures,
sufficiently large in number to secure the accurate and firm clo-
sure of the uterine wound. The superficial layer of sutures may
be introduced after the manner of Lembert, but even this is not
absolutely necessary ; if they are tied tightly and set closely
enough, a single insertion of the needle on each side of the wound
will insure the approximation and closure of the peritoneal cover-
ing of the wound.

Indications for Cesarean Section* — ^The indications for this
operation are relative and absolute.

By an absolute indication is meant some condition which
admits of no other method of delivery. Examples are furnished
in extreme degrees of pelvic contraction — in a flat pelvis, for
instance, in which the true conjugate is less than 6.5 cm. (2.56
in.). The highest grades of kyphosis, osteomalacia, spondylo-
listhesis, and Naegele*s pelves also furnish absolute indications
for Cesarean section, as do foreign growths obstructing the
pelvis, cicatricial contraction of the vagina, and carcinoma of
the cervix and of the rectum.

By a relative indication for Cesarean section is meant a con-
dition that admits of some other method of deliver>% — ^say, by
symphyseotomy or by craniotomy, — but in which the question
arises whether Cesarean section will not give the best result for
mother and child. In a case of this kind the decision is difficult,
and should be left, in part at least, to the woman or to her hus-
band. Ordinarily, the physician is instructed to select the
form of operation least dangerous to the woman. Examples of
a relative indication for Cesarean section are found in flat pelves
with a true conjugate above seven centimeters.

Teclinic of tlie Porro Operation or Celiofiysterectomy. — The
most favorable time, for a Cesarean section is about two weeks
before term. It is not necessary to wait for the beginning of
labor ; in fact, it is better not to do so if the indication for the
operation is absolute. A time of day convenient to the physi-
cian should be selected, and all the preparations should be made
for the operation as for any other abdominal section. Where the
surroundings and the time permit of it, the following regulations,
which govern the abdominal work of the author in general,
should be carried out :

Give the patient, on admission to the hospital, a full hot bath.
Have her kept in bed from the time she enters the hospital until
the operation is performed. Administer pill : strychnin, gr. -^^ ;

782 OBSTETRIC OPERATIONS,

digitalis, gr. \ ; quinin, gr. 2 ; — t. i. d. before operation. Secure
movements of bowels by two drams Rochelle salt every evening.
Have the heart and lungs examined. Examine urine.

Day before Operation. — Diet. — Gruel for breakfast, soup for
dinner, milk-toast for supper, one glass of milk 10 a. m., 4 p. m.,
9 p. M.

Medicifie. — Five p. m., afternoon before operation, ten grains
sulphonal in half a glass of boiling water, cooled down to tempera-
ture that permits of its being drunk, if patient is nervous and
has been sleepless. Nine p. m., half an ounce of Epsom salt in
a tumblerful of water.

Evening before, first cleansing of the abdomen, as follows :

Cleafising. — i. Sterilize the following articles for twenty
minutes at 240°^: soft bristle brush ; absorbent cotton ; one-half
dozen towels ; gauze, unmedicated ; binder ; long gown.

2. The physician, or, under his supervision, the nurse, who
cleanses the abdomen must prepare his or her hands and arms
as though about to operate — namely, remove rings ; scrub with
brush, hot water, and tincture of green soap for ten minutes in
three changes of sterile water ; clean nails with sterile nail -file ;
scrub hands and arms with benzine and then with alcohol ;
immerse hands and arms in bichlorid solution (i : i OCX)) for two
minutes. Then put on the gown.

3. The abdomen, from ensiform to symphysis, and from flank
to flank, must be scrubbed thoroughly (for at least ten minutes)
with soft bristle brush, tincture of green soap, and hot water,
paying special attention to navel and to pubic regions. Wipe
off a razor with cotton and alcohol. Shave the pubis, then scrub
the whole abdomen again thoroughly with alcohol. Cover the
abdomen with the sterile gauze, and put on the binder.

Mornini^ of the Operation. — Give cup of beef-tea at 7 a. m.
Hands of nurse or the doctor cleansed, articles re -sterilized, same
cleansing of abdomen repeated as described above, but, in addition,
before alcohol scrubbing, scrub abdomen with benzine ; wring out
a sterile towel in i : iocmd bichlorid solution, and cover the abdo-
men with the towel ; put over it a thick layer of sterile cotton ;
apply binder. Cathctcrize the woman, just before anesthetiza-
tion, with sterile glass catheter in aseptic manner. Give vaginal
douche, I quart of i : 4000 solution, followed by a little sterile
water. If the bowels have not opened freely, give enema — a
pint of soapsuds and one dram of turpentine.

Instruments for Hystereetomy. — Two scalpels ; one straight
blunt and one large pedicle-scissors ; eight hemostats ; four

^ In the al)senceof an autoclave sterilizer, an Arnold steam sterilizer will do.

CESAREAN SECTION. 783

curved large pedicle-clamps ; four Keen's hemostats ; one large
and one small volsella forceps ; two right and two left aneurysm
needles ; one right and one left sharp-pointed pedicle-needles ;
four curved and two straight needles ; one tissue-forceps ; catgut ;
silk ; ten strands silkworm gut.

Dressings y etc,^ for Abdominal Section. — Autoclave No. i ;
ten towels ; one large binder ; three pieces gauze ; three pieces
cotton ; two six-inch gauze bandages ; two sheets ; three covers
for tables ; three gowns ; three caps ; six brushes ; one bundle
wooden toothpicks for nails ; one large cover for basket ; silk
ligatures ; tubes of catgut in absolute alcohol.

Autoclave No. 2 ; three small white basins ; three small
white pitchers ; one small nickel pan ; seven small gauze pads ;
seven large gauze pads ; one intestinal pad (sixteen inches
square).

The Operation. — With a large scalpel held firmly in the full
hand, a free incision is made from two inches above the umbilicus
to just above the symphysis. This incision may be carried en-
tirely through the abdominal wall in its upper part, as the intes-
tines are out of the way. The abdominal opening is enlarged
with scissors downward as low as possible. An assistant makes
the wound gape while the operator delivers the womb from the
abdominal cavity. A sterile towel is next packed in the perito-
neal cavity behind the uterus. The assistant then approximates
the edges of the abdominal wound as closely as possible around
and above the cervix, at the same time squeezing the latter with
his outspread hands. With a few rapid but light strokes of the
knife the operator makes an incision an inch in length through the
uterine muscle, but not through the membranes, so as not to cut
the child. Then, with one rapid movement of the left hand and
arm, the uterine wall is torn down to the internal os, the mem-
branes are ruptured, the placenta, if in the way, is detached and
pushed aside, the child is seized by the most accessible part, —
shoulder or leg, — is delivered, and, with the placenta still attached
to it, is dropped into a sterile sheet spread out over the out-
stretched arms of an assistant who stands directly at the opera-
tor's left hand, and whose duty it is to revive the child, if
asphyxiated, and to tie and cut the cord. Up to this point the
operation rarely requires seventy-five seconds. Then follows
an easy hysterectomy : the ligation of the ovarian arteries and
of the arteries of the round ligaments ; the application of clamps ;
the cutting of the broad ligaments ; the preparation of peritoneal
flaps ; amputation of the womb ; the ligation of the uterine
arteries ; and the oversewing of the stump, which is dropped.

The abdominal wall may be closed by close-set, interrupted

784 OBSTETRIC OFEKATIONS.

stitches, — the easiest plan for a beginner, — or by a few thr(
anti-through, interrupted silkworm-gut sutures, which si
serve to sphnt the wound— the peritoneum, the fascia, and the
skin being united by separate running stitches of catgut.

The tecfank of tlie Siinzer opentton is tlie same up to the point
when the child and appendages have been extracted from the
womb except that the uterine wall must not be torn but should
be clean cut with scissors. Then, instead of amputating the
uterus, the uterine wound is carefully brought together by three
sets of sutures ; one interrupted, of fine silk, set about an inch
apart, inserted under the peritoneum running across the lower part
of the wound above the endometrium and emerging on the oppo-

site side under the peritoneum ; the second, a running C3t-{

stitch in two tiers, embracing the muscle only and ending fip|

site the point where it began, so that there is but one knot ; the
third, a running Lembert stitch of fine silk in the peritoneum,
beginning above and running down, the needle being inclined
upward at each insertion to allow for the pull downward of the
suture when it is tightened (Figs. 593 and 594)-

Fritsch's proposition to make the incision across the fundus
uteri from tube to tube, instead of in the anterior abdominal wall,
is receiving a practical trial in Germany. There seems to b
decided advantage in it except that the uterine wound is as fi
possible from the cervical canal, and, therefore, from subscqui

CESAftEAX SECTION/. 78$

contamination. But should leakage occur, the woman is de-
prived of a safeguard to which she has often owed her life,
namely, adhesions bftwet'n the uterine and ;ibdominal walls.

The Choice of Celiohysterectomy or of Celiobysterotomy
in a Case Requiring Cesarean Section. — Tiie impression pre-
vails that the classical conservative Cesarean section, or celJo-
hysterotomy, is a safer and better operation than the Porro-
Cesarean section, or celiohysterectomy — the removal of the
uterus after the extraction of the child. It is the general belief
that hysterectomy should only be performed when a woman has
been very long In labor and many futile attempts to extract the
child had been made, probably infecting the endometrium ; if there

'ig- 594-^A, The upper licr of Ihe ninninE calgui slitcli ; B, tlie running I.einbett

is uncontrollable hemorrhage from uterine atony ; incase of in-
superable obstacle to drainage of the lochia, as a cancer of the
cervix or a bony tumor of the pelvis ; or in the presence of a
uterine tumor which could only be removed with the uterus. It
is the author's conviction, however, that celiohysterectomy in a
case requiring Cesarean section is the preferable operation, with
a lower mortality and a greater freedom from complications not
only in the puerperium. but in the patient's future existence.

It is easy to understand the prejudice against the Porro
operation and in favor of the classical Cesarean section, if one
recalls the history of abdominal and uterine section for the ter-
mination of insuperably obstructed labors.

786 OBSTETRIC OPERATIONS.

During the first two hundred and sixty-six years in which
Cesarean section was practised upon the living woman the mor-
tality of the operation had been so frightful that any expedient
to avoid it was thought justifiable. Induction of abortion for
deformed pelvis, symphyseotomy, laparo-elytrotomy, each had
its origin in a desire to escape the dangers of Cesarean section,
while, for the same reason, much ingenuity was devoted to the
improvement of the technic and to the invention of new instru-
ments in the oldest obstetrical operation — embryotomy.

Finally, in the spring of 1876, Edward Porro performed the
first successful celiohysterectomy for obstructed labor. This
method of operating so obviously avoided the most fatal dangers
of the older plan that it was widely adopted, and in the hands of
such men as Carl Braun, Breisky, Leopold, Krassowsky, Frank,
Fehling, Tait, and Porro himself, the mortality of Cesarean sec-
tion was reduced to less than half of what it had been. Scarcely,
however, were these results beginning to be appreciated by the
medical world at large when Sanger proposed the close and
accurate suturing of the uterine wound, including the peritoneal
covering. Coincident almost with the adoption of this great
improvement in the operation there began the aseptic era in ab-
dominal surgery and the appreciation of the common-sense rule
that Cesarean section, when required at all, should not be post-
poned until the patient is at the last gasp, after every other
means of delivery had been tried in vain.

By a combination of three factors — close suturing of the uter-
ine wound, aseptic technic, and early operations — results were
secured of such brilliancy as to throw the achievements of Porro
and his followers completely in the shade. Meanwhile, however.
Cesarean section by celiohysterectomy had undergone an evolu-
tion from which attention was distracted by the glamour of the
results following the Sanger operation. All gynecologists are
familiar with the improvement in the technic of hysterectomy
which has made the intraperitoneal treatment of the stump a
much safer as well as a much more satisfactory method of oper-
ating than the extraperitoneal fixation of the cervix formerly was.
In the past six years a number of Cesarean sections followed
by hysterectomy have been performed by the best and most
modern technic — ligating the arteries of the broad ligament,
dropping the cervix and sewing over it a peritoneal flap. It is
too soon, however, to collect statistics of this operation and to
compare its results with those of celiohysterotomy. There are
disadvantages, moreover, in the mere statistical study of any sub-
ject which the practical worker has often reason to appreciate.
Without an array of figures, therefore, to support his statement.

CESAREAN SECTION. 787

the author can say, from his own experience, that not only does
it add nothing to the danger of a Cesarean section to remove the
womb, but, on the contrary, it diminishes the risk of the operation,
for it ehminates the possibiHty of postpartum hemorrhage and les-
sens enormously the chance of puerperal infection. Certain com-
plications in the puerperium also, as well as others at later periods
in the individual's life, are surely avoided by a hysterectomy.
These are : retention and decomposition of the lochial dis-
charge, to which the undilated cervical canal does not give free
vent if the operation is performed before labor ; adhesions be-
tween the anterior uterine and abdominal walls ; persistent fistulae
communicating with the uterine cavity ; rupture of the uterus in
subsequent pregnancies and labors, and the necessity for repeated
Cesarean sections if the woman is allowed to become pregnant
again.

In consideration of these incontrovertible facts it is clear that
the statistics of the future, studied with discrimination, and tak-
ing into account the woman's life-history, will demonstrate the
superiority in results of the modern Porro operation over the
conservative classical Cesarean section.

Whatever one's predilection may be in favor of hysterotomy
or hysterectomy, there are certain conditions in parturient women
which forbid a freedom of choice and compel the selection of the
latter operation. It is important, therefore, to learn the propor-
tion of cases in which the Porro operation must be performed
and a mere hysterotomy should not be relied upon.

The author's experience in Cesarean section amounts to
23 operations, performed for the following indications : fibroid
tumors, 2 ; dermoid cysts impacted in pelvis, 2 ; cancer of the
cervix, i ; partial atresia of vagina, i ; contracted pelves, 17, of
which there were i kyphotic pelvis, i obliquely contracted and
flat, I transversely contracted, 14 flat rachitic. Out of this
number it would have been absolutely necessary to perform a
Porro operation in 12 cases. In 6 of the operations for con-
tracted pelvis the patient had been in labor many hours. Futile
attempts at delivery had been made with forceps, and in two in-
stances by craniotomy. The uterus was already infected, and
the birth-canal injured by slipping instruments or by the exercise
of unjustifiable force in efforts at extraction. In one of the cases
of impacted dermoids the woman had been in labor four days.
The pelvic connective tissue and lower uterine segment were ex-
traordinarily edematous, and the endometrium was almost black
in color. In the two cases of fibroids attached to the lower
uterine segment a hysterectomy was necessary to remove the
tumors. In the cases of atresia of the vagina and of cancer

788 OBSTETRIC OPERATIONS.

of the cervix it was obviously improper to leave the womb
behind.

If the author may judge by his experience alone, it appears
that a Porro operation is required in practice a little more fre-
quently than the so-called *' conservative Cesarean section.'*^

It is fair to assume, therefore, that any physician who may
be called upon to perform a Cesarean section should always be
prepared for a hysterectomy as a part of a Cesarean section.

Whether the uterus should be removed in the majority of
cases depends upon one's viewpoint in regard to the justifiability
of repeated pregnancies in women who can only be delivered by
a Cesarean section. It is perfectly plain to the author s mind
that a woman should not be condemned to the probability of a
repeated Cesarean section unless she herself and her husband
demand it. This, however, is a remote contingency. In al-
most every case in which the subject is submitted to the patient
or to her husband, the surgeon is urgently requested to prevent
the possibility of another conception.

Even if it were possible for the most skilful and experienced
operator, dealing with patients in the most favorable condition
and amid the best surroundings, to eliminate the dangers of
Cesarean section, it would still be impossible to be certain that a
woman would, on the next occasion, be so situated that she could
command the best attention. Hence, Cesarean section is and \*ill
remain a dangerous procedure with a considerable mortality.

Taking into account the unavoidable, though small, mortality
of Cesarean section under the most favorable circumstances ;
considering, moreover, the impossibility of always securing the
best circumstances in many cases, it seems perfectly clear that
it is unjustifiable to subject a woman with an insuperably ob-
structed pelvis to the dangers of subsequent pregnancies and of
a repeated Cesarean section. Once this point is conceded, it \s
unnecessary to argue further for a hysterectomy. No one can
contrast in actual practice the greater facility and rapidity with
which a Porro operation can be done, the entire freedom from
many of the risks of the puerperium after the removal of the
uterus, the impossibility of many complications that are likely in
the Sanger operation, without preferring the former to the latter
operation.

^ I,eo(xild in loo Cesarean sections performed the Porro operation twenty-nine
times (/(>r. cit.).

PART VII.
THE NEW-BORN INFANT.

CHAPTER I.

PhysioIosT of the New-bom Infant*

Respiration. — ^There are two factors which explain the in-
stitution of respiration: (i) External irritation, the result of a
change of environment from a liquid medium, with a tempera-
ture of 99° F., to the air, with a temperature of 70° F., causing a
reflex action of all the muscles, including those of respiration.
(2) The maternal supply of oxygen being cut off from the fetal
blood as the placenta is separated or compressed, there is an
accumulation of CO,, the primary action of which is that of a
stimulant to the respiratory apparatus and to the brain-centers
governing respiration. The power of the latter factor is often
shown during or before labor. Should anything diminish the
supply of oxygen to the fetal blood, such as pressure upon the
cord, there is an immediate effort to respire. If the membranes
are unruptured, liquor amnii is sucked into the lungs. If the
head is in the vagina, or if air is admitted to the uterus after rup-
ture of the membranes, respiration may be begun long before
birth, and the child has actually been heard to cry aloud within
the womb (vagitus uterinus).

The rate of respiration at birth is 44 to the minute, sinking
shortly to 35.

The weight at birth is about 7 V^ pounds. There is a steady
increase of about i i/^ pounds each month before and i pound
after the fourth month.

Weight.

Month.

Pounds.

7-75

9.5

12.5

Weight,

Month.

Pounds.

789

790 THE NEWBORN INFANT.

There is normally a loss of 5 J^ ounces, on the average, during
the first two to five days, which is usually made up by the end of
the first week. Some children, however, gain steadily from birth.

Digestion is accomplished by the digestive juices, except the
diastatic ferment of the pancreas and of the salivary glands. It
is partially dependent upon the bacteria normally present in the
alimentary tract. A knowledge of the capacity of the stomach
is important if one would avoid the common error of overfeed-
ing a new-born infant.

The capacity of the infant's stomach is, on the average, dur-
ing the first week, 46 c.c. (1.5 fl. oz.) ; second week, jZ c.c. (2.5
fl. oz.) ; third and fourth weeks, 85 c.c. (nearly 3 fl. oz.) ; third
month, 140 c.c. (nearly 5 fl. oz.) ; fifth month, 260 c.c. (about
9 fl. oz.) ; ninth month, 375 c.c. (12.5 fl. oz.).

The greater the infant's weight, the greater the gastric
capacity. One one-hundredth of the body-weight plus one
gram each day is a fairly accurate formula for the expression of
gastric capacity in the new-born. In a child of normal weight
the capacity should be one ounce at birth and an increase of one
ounce per month up to the sixth month, after which it is some-
what less (Holt).

The Position of Stomacli. — Its axis is almost longitudinal,
which in part explains the frequent regurgitation and vomiting
of early infancy. It is placed high on the left side under the
false ribs, so that it is influenced by the movement of the float-
ing ribs in respiration.

Excretions. — Tlie urine is albuminous for the first few weeks.
The quantity is difficult to estimate. It is always acid in reac-
tion. The specific gravity is low, 1003—5. ^ trace of sugar is
often found in breast-fed infants and in those fed upon an arti-
ficial food containin<^ sugar of milk. The urine is voided six to
twenty times in twenty-four hours. It docs not, as a rule, stain
the diapers, and the mistake may thus be made of supposing
none to have been voided.

The movements from the bowels consists for the first fortv-
eif^ht hours of meconium, a substance greenish-black in color,
and consisting mainly of bile-salts and coloring matter. Later,
the evacuations become light yellow, are not formed, are sour in
smell, acid in reaction, and have a slightly fecal odor. The nor-
mal frcquencx' of evacuation is from three to four times in the
twenty-four hours.

The temperature is always slightly elevated directly after
birth. It then sinks a little below normal. Its subsequent course
is marked by considerable irregularity, with the variations usu-
ally above 9<S°. Conij)arativcIy slight causes produce high tem-
peratures.

PHVSJOLOGY OF THE XEW-BORX INEAXT.

791

The eyesight is always hypermetropic.

The pulse beaLs from 12510 160 in the minute. It should be
counted by Hsteniug to the beat of the heart, and not by feeling
the pulse, as in an older child or adult.

The blood has a total bulk to the body-weight of 8 per cent;
there are six to seven millions red blood-corpuscles to the cubic
millimeter; they are more spherical than in the older child, and
do not tend to form rouleaux. Shadow corpuscles are abundant.
White blood-corpuscles are more numerous, viscid, and deliques-
cent than in the adult. There is a large amount of hemoglobin

umbilical ve»clc.

at birth compared with the mother's blood — 120.3 percent, in
the infant and 93. S per cent, in the mother. At thirty-six to
forty-eight hours after birth the percentage of hemoglobin is
highest, and then begins to diminish. ^ The ordinary jaundice
of the new-born infant is due to the superabundance of red blood-
corpuscles which are destroyed in the liver, giving rise to an
excess of bile-pigment. It is reasonable to suppose that it may
also be in part hematogenic, the destruction of the red blood-
corpuscles setting free a certain amount of coloring matter in
the biood, which is directly absorbed by the tissue.

' CaUaneo. "Diss. Inaiig.," Bnsel, 1891.

792

THE NEW-BORN INFANT.

The heart exhibits a transition from the fetal to the infantil

circulation by the closure of the foramen ovale, the obliteratJoi
of the ductus arteriosus, and the disappearance of the Eustachiai
valve (Figs. 595. 596).

The umbilical cord, after twentj'-fuur hours, shows a line c
demarcation at its base. There is then a necrosis of the a
cdVcring, a mummification of the raucous tissue, and a destru

Fig, 596, — The circulation in tbe mature fetus before birth.

tion of its vessels. The cord drops off about the fourth day. Iq
detachment i.s followed by the retraction of the granulatit^
stump within the umbilical nng.

Abnormalities in the Physiology of Premature Infants.-

The two main deviations are low temperature — variations beloi
98° — and inability to ingest and digest food.

The management of premature infants consists in incubatiol
and gavage. In the absence of a specially constructed incubatoi

PHYSIOLOCY OF THE NEW-BORN INFANT.

791

such as Tamier's or Auvard's, one can be readily improvised
with an ordinary infant's bath-tub, several layers of cotton-wool
or lambs' wool, and a number of bottles filled with hot water.
Gavage is the regular feeding of the infant with freshly drawn

Fig. 597. — Modified Auvnrd incuboWr; v. Glass plate of thf movable lid 6
vcntilaling lube cuntnimug small rolan' fan; K, vcnlilBting slides M, hot-waler
cuu ; O, slide clcuing hot-ait chamljcr.

FiB- 59S-

rd incubator (Mg. 597).

mother's milk through a small soft catheter passed into the
.stomach at each feeding. A more convenient and quite as effi-
cient a plan is to draw the mother's milk «ith a breast-pump
and to feed it to the child through a medicine dropper, a few
drops beiny allowed to trickle into its mouth at a time. The

THE NEWBORN INFANT.

794

intervals between feedings should be an hour and t
administered should at first be no more than a dram,
should not be bathed, but should receive, instead, a daily rub
with warm oil. It should not be clothed, but should be buried
in wool except its face. A diaper should be put under but not

j the quand^^l
tm. The chil^H

around the buttocks, and must be changed often enough \
prevent chafing.

The mortality of this treatment has so much improved the
chances of a premature infant that at six months, according lo
Tamier's statistics, 2Z per cent, arc saved ; at seven months, j8 a

PHYSIOLOGY OF THE NEWBORN INFANT. 795

per cent, are saved. Charles,^ from an analysis of 932 prematuroi
births, found that at six months 10 per cent, were saved ; at six
and a half, 20 per cent. ; at seven, 40 per cent. ; at seven and a
half, 75 per cent.

Sclerema is a disease of premature infants, seen most often
in lying-in hospitals. The most prominent symptom is a har-
dening of the skin, beginning in the legs and spreading over
the body, usually sparing the breast and abdomen. Jaundice or
a hemorrhagic tendency often accompanies it. The temperature
is very low, remaining at or below 95^. The pathology of the
disease is not well understood. It has been ascribed to edema.
The most probable explanation is that the large excess of
stearin and palmitin in the subcutaneous fat of infants solidifies
when the temperature falls below normal. The condition is a
grave one and is likely to be fatal. The treatment consists in
incubation, stimulation, and support.

The Manag^ement of the New-born Infant. — Clothing. — An
infant should be clothed in winter as follows : A binder, of
flannel or knit wool, twice around abdomen ; a knit shirt, diaper,
knit shoes, and two skirts, the first flannel (in midsummer, linen),
and finally its dress. The skirts should be supported from the
shoulders by sleeves or tapes. Each skirt should be made with
a body, and not with a band. A knit jacket may be worn over
the dress. A light flannel shawl or cap is desirable to protect
the child's head from cold, when it is lifted from its crib or
carried to another room.

As an infant urinates frequently, the diapers are changed
about twenty to twenty-four times a day. The buttocks should
be carefully dried and powdered with compound talcum, borated
talcum, oxid of zinc and lycopodium, or rice-flour powder.

Feeding:. — Human Milk, — The secretion is established at the
end of forty-eight hours. It derives its origin from an over-
growth of epithelial cells lining the ducts of the mammary glands,
their infiltration with fat, and subsequent rupture. The specific
gravity is 1024-35, the reaction alkaline. Each minute fat-
globule is surrounded by a pellicle of serum-albumin.

Chemical Constitution.

Meigs. Vogkl. Gautrelet.

Water 87.163 89.5 88.1

Fat 4.283 3.5 4.0

Casein 1. 046 2.0 2.2

Sugar 7407 4.8 6.2

Ash .0.101 0.17 0.5

* ** Viability des nouveau n6s \ terme et avant terrae," ** Archives d*Obstet.,*'
1893, p. 412.

796 THE NE IV BORN INFANT.

I Fat. — ^This constituent of human milk is subject to wide
variations in quantity under the influence of diet and general
health. Under normal conditions, however, it stands quite con-
stantly at four per cent.

Proteids of Milk. — The proteids of milk are casein and iact-
albumin.

Casein. — Casein is, strictly speaking, the curd of milk, formed
by a digestive ferment acting upon *' caseinogen," a proteid
analogous to fibrinogen, myosinogen. Caseinogen is a peculiar
substance, neither an alkali-albumin nor a globulin, but occupy-
ing a distinct position among proteids.

Lactalbumin. — A proteid resembling closely serum-albumin,
but somewhat different from it. It is present in small quantities
— one-half of one per cent. When the milk is curdled, a new
proteid appears in whey, called ** whey-proteid,** which is soluble
and non-coagulable by heat.

The sugar is lactose ; it is not strong in sweetening properties.

The ash of human milk is made up mainly of potassium,
sodium, calcium, and phosphoric acid.

The quantity of milk at each nursing is difficult to determine.
It maybe estimated by: (i) The infant's gain in weight after
each feeding. This is not constant, varying from three to six
ounces. (2) The capacity of the infant's stomach. (3) The
quantity secreted in twenty -four hours, divided by the number of
nursings. At the end of the seventh day the quantity in twenty-
four hours is fourteen ounces ; at the end of the fourth week,
two pints.

If the mother can not nurse her child, the best substitute,
theoretically, is a wet-nurse.

The selection of a wet-nurse should be governed by the fol-
lowing considerations :

She should have milk of good quality^ which is best judged
by the appearance of her own child.

She should, preferably, be a multipara, and of suitable age ;
her child should be, approximately, the same age as the one to
be nursed ; her nipples should be well shaped ; and it is an ad-
vantage to have made a chemical analysis of her milk.

She should have an equable disposition and an absence of
disagreeable qualities.

Above all. she should not have syphilis. As a matter of fact,
wet-nurses arc so inconvenient and disagreeable in the average
household, and the results of artificial feeding have so markedly
improved, that the vast majority of children who are not nursed
by their mothers are raised on the bottle.

Artificial Feeding^. — Asses' and goats' milk are more like

PHYSIOLOGY OF THE NEWBORN INFANT. 797

human milk than is cows' milk, but, as they are not conveniently
procurable, the last is universally used. To appreciate why so
large a proportion of artificially fed children die annually, particu-
larly in the hot summer months, it is sufficient to glance at the
differences between cows* and human milk. ^ The most important
differences may be briefly tabulated as follows :

Gross Appearances, — Cows* — a dead white in color, and
opaque. Human — often yellow ; sometimes bluish. More
translucent.

Reaction, — Cows* — acid. Human — alkaline.

Specific Gravity, — Cows' — 1 030-3 5. H uman — 1 024-3 5.

Curd Comparison, — The coagulum produced by a digesting
ferment, as rennet, is dense, tough, and digested with difficulty
in cows* milk ; light, flocculent, and easily digested in human
milk.

This difference is due merely to the larger quantity of case-
inogen in cows* milk, and to the acidity. Dilute cows* milk and
make it alkaline, and the curd, on the addition of rennet, is as
light and flocculent as in human milk.

Chemical Comparison, — Cows* milk contains more casein and
less sugar.

Comparative Analyses.

Mkics. Vogel. Lehman. Gautrelet.

Human. Cows'. Human. Cows'. Human. Cows'.

Water 87.16 87. 1 89.5 87.5 88.1 85.61

Fat 4.28 4.20 3.5 3.5 4.0 4.0

Casein 1.04 3.25 2.0 3.5 2.2 3.5

Sugar 7.40 5.0 4.8 4.8 6.2 6.0

Ash o. 10 0.52 0.17 0.75 0.5 0.85

Histological Comparison, — It is asserted that the albuminous
envelope surrounding the fat-globules is thicker and tougher in
cows* milk. Colostrum-corpuscles are found in human milk,
normally, up to the eighth or tenth day. They return under
influences interfering with lactation, as heretofore described.

Bacteriological Comparison. — Human milk comes from the
breast practically sterile. Cows' milk in cities, particularly in
hot weather, after twenty-four hours, swarms with all kinds of
pathogenic and non-pathogenic micro-organisms and their pro-
ducts, some of which are virulent toxins.

Quantitative Comparison, — Human milk is furnished in quan-

* According to official statements relating to the Russian foundling hospitals at
St. Petersburg and Moscow, about 1,000,000 newly bom children have been given
over to them during the last hundred years, most of them illegitimate. Of this large
number, nearly 800,000 have died in the first months or first years of their existence.
A well-known authority on statistics satirically calls it '* chronischer Kindermord
auf Staatskosten " (** chronic infanticide at the cost of the State").

79^ THE NEW- BORN INFANT.

tity and at intervals suitable for the infant. Artificially fed
children are often overfed.

Preparation of an Artificial Food. — In making an artificial food
with cows' milk as a basis, three factors must be borne in mind :
the quantity required, the differences in chemical composition
and reaction, and the microbic infection. The first may be regu-
lated by the following table, based upon a study of the capacity
of the infantile stomach :

^F^^mNr^cT Amount of Food Total Amoittt

Age. Interval. .wT^irKiTv at Each in Twenty-

Fouk Hours. F=h'"''0- ^^^ Hours.

First week 2 hrs. lO I oz. lo ozs.

Second to fourth week . . 2 *' 9 i^ ozs. 13^ **

Second to third month . . 3 '* 6 3 •' 18

Third to fourth month . . 3 " 6 4 •* 24

Fourth to fifth month . . 3 ** 6 4-4 >^ *' 24-27

Sixth month 3 ** 6 5 *• 30

Eighth month 3 ** 6 6 " 36

Tenth month 3 ** 5 8 ♦« 40

««

44
44
4<
44

The difference in chemical composition and reaction may be
removed by diluting the whole to reduce the casein, adding
cream and milk-sugar, and making the mixture alkaline. The
microbic infection of cows' milk may be obviated by pasteuriza-
tion.^ The following formula accomplishes these purposes :

Milk for one lx)ttle 4 drams

Water (boiled) 5 **

Cream I dram

Lime-water I **

Milk-sugar lo grains.

To pasteurize the milk, six bottles should be made up for
the ensuing twelve hours.

Stopper the mouth of each bottle with dry, baked cotton ;
put them in a receptacle with a lid ; pour boihng water around
them to the level of the milk in the bottles ; put on the lid and
let stand off the stove for thirty minutes.

Set aside to cool and then put in a refrigerator.

Apply a plain rubber nipple to the bottle before use.

Warm it to blood heat in a warming cup before giving it to
the child.

Cleansing. — The infant should receive a daily bath in the
middle of the day in the warmest part of the room. The tem-
perature of the water should be not much over 90°. The
nurse, whose hands are commonly insensible to hot water,

' By this ttTm is meant the subjection of the milk to a temperature of l67°-i75°,
which sterilizes it but does not impair its nutritive value as steam sterilization or
boiling docs.

INJURIES TO THE INFANT DURING LABOR, 799

should be required to use a bath thermometer. Castile-soap
and a soft sponge should be used, and care must be exercised
not to irritate the eyes. For the first week the child should be
simply sponged on the nurse's lap. After that, if it is strong
and vigorous, it may be immersed in the tub.

Airing:. — In summer the baby may be taken out after the
second month ; in winter after the third month, for a short time,
in the warmest part of the day.

The resting: place should be a crib, and not a cradle.

CHAPTER II.

Patholo^T of the New-bom Infant*
INJURIES TO THE INFANT DURING LABOR.

{Classified According to the Seat of Injury.)

Brain. — Injury to the brain is most frequently the result of
the faulty use of forceps or of the violent extraction of the after-
coming head. It may be a meningeal hemorrhage, varying
in extent from the rupture of a small vessel and a slight extrava-
sation of blood to the laceration of the longitudinal sinus and a
fatal intracranial hemorrhage. If less in degree, the child may
live to adult age, but is apt to show impaired physical or mental
development. The brain-substance may be crushed. Injuries
may be inflicted upon the brain not so grave, but affecting intel-
lectual or physical centers, and the subsequent mental or physical
development of the individual. There may be simply com-
pression of the brain, causing perhaps asphyxia.

Persistent priapism may be seen occasionally, as a result of
injury to the brain or cord. ^

Peripheral Nerves. — ^The facial and brachial plexuses are the
peripheral nerves most frequently damaged. The majority of
cases of facial hemiplegia are due to the faulty use of forceps.
Recovery may be expected, usually in the course of a week.
Should this fail to occur, the faradic current may be used with
advantage. Facial palsies at birth are usually unilateral and
transitory ; they may, however, be bilateral and permanent. The

^ In one of my cases priapism persisted for two weeks, much to the dismay of
the mother, who feared it would be permanent.

8oo

THE NEIV.BORW IXFANT.

brachial palsies ri;sult from unskilled attempts at extracting I
shoulders and arms, and are likely to be permanent.

Skull. — Spoon-shaped depressions of parietal or frontal bones

may be caused by a prominent promontorj- or by forceps. It
has been suggestL'd to elevate the depression by pneumatic trac-
tion or by trephining.

Fractures, if compound, require an aseptic dressing.
covciy, even from so grave an injury, sometimes occurs.

Fig. 6oi. — SpooD-shiped ilepr

Distortion of the head is very common, almost constant. Itf

variations in form are the result of the different presentations and!
position.^. The deformity, even though very marked, disappear*;^
wilJiin the first three days (Figs, 603-608).

Scalp. — Caput Succedaneum. — A serous infiltration of that
portion of the presenting part corresponding to the external os.
It disappears in two or three days, and requires no treatment

INJURIES TO THE INFANT DURING LABOR. 80I

Fig. 605. — Normal vertex (Schroeder). Fig. 606. — Outline of head after de-

liTerj, (he brow presenling (Budinj,

8o2

THE NElV-BORy IXf'AXT.

Cephalhematoma is a more important condition, and is to be
distinguished frnm a caput succedaneura. It occurs about once in
two hundred cases. Usually two or three days after birth a swell-
ing develops, rapidly increasing in size, possessing the physical
signs of a cystic tumor, distinctly confined by the boundanes of
one of the cranial bones. It may be bilateral. It may occupy
the parietal and the occipital bones, and it may possibly develop

before birth. It is due to a subpericranial hemorrhage,
lifts the pericranium from the bone, irritates it, and stimulate!) it
to bone-production, thus giving rise to a bony sensation at the
lifted edges of the pericranium, and later to a peculiar crackling
or crepitus over the surface of the tumor, due to the movement
of the thin bone-plates on one another. Non-interference is the
treatment, except when the hemorrhage is exces.sive or suppura-
tion occurs. The former may be controlled by pressure \

INJURIES TO THE INFANT DURING LABOR.

803

cold ; the latter requires incision and drainajfe, with strict asepsis.
In spite of tlic greatest care, septic meningitis may develop.

Contuseii and laceraUd wounds, usually the result of a
forceps operation, are to be treated on general surgical prin-

— The vitality of the scalp may be destroyed by for-
ceps or by prolonged pressure from the pelvic bones, and sloughs
may appear in the first few daj's after birtli. They require the
ordinarj' surgical treatment
for the same condition any-
where on the body.

Face. — A caput succe-
daneiim may occupy the
face if it presented in labor.
The eyes and the mouth
may be injured by careless
examinations or by violent
extraction of the after-com-
ing head. The former may
be injured by the forceps.
The globes may be luxated
to complete exophthalmos ;
the recti muscles may be
[Kirmanently paralyzed ;
there maj- be subconjunc-
tival or palpebral ecchy-
moses, edema of the lids,
and temporary ptosis ; frac-
ture in the roof of the
orbit ; exudation of blood
into the anterior chamber.
The cheeks, temples, and
forehead may be bruised,
crushed, or cut by forceps.
Hematomata may develop

in the cheeks within twenty-four hours of birth. The blood-
tumors should be let alone, as in the case of a cephalhematoma.

Neck. — There may be injury and thrombosis of the neck-
muscles, with reactive inflammation, most frequently of the
stemocleidoma.stoid, with the development of torticollis. This
sort of wry-neck usually recovers without treatment.

Fracture, Dislocatton, or Decftpltation, — The author has been
told the details by ej'e- witnesses of three cases in which the head
was pulled off after version. In each instance Cesarean section
was done to extract the head. The women all died. Crani-

8o4 THE NEM'-BOKX INFANT.

otomy should obviously have bt.vn the operation for the extrac-
tion of tlie head.

Tlierc is occasionally injury to the cervical spine and to the
larynx and trachea, in consequence of the excessive twisting of
the neck that occurs when the occiput turns forward from a
posterior position and the shoulders do not follow the movement
of the head.

Limbs. — Fractures, which are usually a separation of diaph-
ysts and epiphysis, require, in the case of the lower extremities,
surgical fixation, cvtension, and a plaster bandage. In the case
of the arms, fixation in the Velpeau position by a jacket with
only one arm-hole, for the sound arm. Union is pnimpL Frac-
tures are usually the result of faulty management on the physi-
cian's part, but they may be spontaneous. Avulsion of ihc

limbs sometimes occurs in efforts to extract a premature
macerated fetus.

Trunk. — Perforations of the groin and perineum may be due
to the use of a blunt hook or a forceps applied to the breccli,
There may be rupture of some important viscus, like the spleen,
liver, or lungs, with fatal hemorrhage into the peritoneal "r
pleural cavities, especially in syphilitic children ; or visceral
hemorrhage may occur, as in the kidney, without actual rupture,
but to a sufficient degree to abrogate the functions of the organ.
Fracture of the clavicle in extracting the after-coming head may
result in the puncture of the lung by the broken end of the bone
and in fatal emphy.sema. The kidney, spleen, and liver have
been ruptured in attempts to extract the breech. Subcapsular
hemorrhages in these organs arc" observed quite frequently. In
the pleura there are often ecchymotic spots in asphyxiated t

INJURIES TO THE INFANT DURING LABOR.

80s

dren, with minute but multiple extravasations in lungs and brain.
The pleura may be lacerated, with a hematothorax as the result*
The body may remain distorted for some time as the result of a
face presentation, and there may be ecchymoses upon the body
if there is a presentation of the trunk.

Fig. 615. — Back presentalion. Fig. 616, — Felus after ■ presenlation of

DisposilJQn of the sensaDguineoiu the back, shoulder, and elbow. Disposition
ecchymosis (Budin|. of serosanguineous ecchjmosis (Budio).

Bowel. — The large bowel may rupture from preexisting
ulceration or necrosis, usually at the sigmoid or other flexures.

breech and Irunlc.

8o6 THE NEW-BORN INFANT.

Asphyxia. — Asphyxia of the new-bom child results in con-
sequence of an insufficient supply of oxygen to the blood. To
understand its causes it is necessary to review the

Physiology of the institution of Respiration. — The sudden
changes in the environment of the fetus (from a liquid medium
at 99° to the air at 70°) produces an exaggerated stimulation of
all the muscles to reflex action, including the muscles of respira-
tion. Placental respiration is, moreover, abolished, and the
accumulated CO, primarily stimulates, but finally paralyzes, the
respiratory center.

The causes of asphyxia are :

First, intra-uterine. Under this head come —

Fetal inspiration.

Any interference with placental respiration, paralyzing the
brain-centers, as premature detachment of placenta ; coiling,
compression, or prolapse of the cord ; diminution of the caliber
of the umbilical vessels, as from syphilitic periphlebitis ; excess-
ive and prolonged uterine contraction.

Prolonged pressure on the fetal brain by the pelvis or by for-
ceps, paralyzing the brain-centers.

Grave systemic diseases of the mother, and accidents, includ-
ing hemorrhage, uterine or pulmonary.

Anomalies or diseases of the fetus, preventing the entrance of
air into the respiratory tract, or preventing the proper distribu-
tion of blood from right ventricle to the lungs, as a patulous fora-
men ovale or atresia of the pulmonary artery.

Second, extra-uterine causes, as —

Placing the infant after birth in a position unfavorable for
respiration.

Precipitate labor.

Interference with the access of air to respiratory passages, as
by a caul, unruptured membranes, or maternal discharges.

Asphyxia neonatorum is divided into two stages :

1. Asphyxia Livida. — In this stage there is an accumula-
tion of CO^ in the blood, yet the circulation continues and the
reflexes are preserved. The prognosis of this stage is favorable.

2. AspJiyxia Pallida. — This is an advanced stage of the for-
mer, characterized by weakness of the heart, slowing of its pulsa-
tions, and the abolition of the reflexes. The prognosis of this
stage is naturally unfavorable.

Treatment. — If possible, asphyxia should be prevented by
removing the possible causes during labor. The treatment of
the condition after labor consists of:

I. Extraction of mucus from the throat and fauces by hold-
ing the child by the feet and cleaning the mouth with a finger.

INJURIES TO THE INFANT DURING LABOR.

807

2. The application of exaggerated stimuli to respiration,
as slapping of the buttocks, vigorous rubbing of the back and
chest ; immersing the body in warm water, and pouring ice-water
on the epigastrium ; applying electricity, if practicable, preferably
in the shape of a faradic current, one pole being placed on the
epigastrium and the other applied on the sternum, flanks, and
thighs. The electric brush is most efficacious. In the pallid
variety only the most powerful of these stimuli are useful.

3. Artificial respiration is induced by one or all of several
methods.

Sylvester's is not to be recommended because the pectoral
muscles of the infant are too weak to inflate the chest when
pulled upon by the manipulation of the arms.

Fig. 617, — Schullze's method of arliRcial

Marshall Hall's method, modified to suit the requirements of
the new-born infant by suspending it in a towel, and thus rolling
it from side to side, is sometimes useful.

Schultze's method is one of the best. The infant should be
wrapped in a towel to protect it from being chilled, should be
held as shown in figure 617, and should be swung between
the physician's knees and over his shoulder ; after practising
the swinging movements fifteen to twenty times, the child should
be immersed for a few seconds in warm water to raise its tem-
perature, when the movements may be repeated,

Mouth-to-mouth insufflation ranks with Schultze's method,
or is superior to it. The exit of air from the lungs should be

8o8 THE NEWBORN INFANT.

facilitated by placing the infant's neck over a mug or cup with
the head extended, and after inflating the lungs flexing the head
and compressing the chest. The nose should not be held to
prevent the escape of air, as is sometimes advised. The physi-
cian draws a full breath and through a clean towel spread over
the child's face blows the first part of the expired air into the
child's mouth. The open nostrils serve as safety-valves. The
air-vesicles of the lungs are not so likely to be damaged.

Catheterization of the larynx with a soft catheter and direct
inflation of the lungs is only advisable if there is tumefaction of
the neck or some other mechanical interference with the entrance
of air into the larynx. Great care must be exercised not to
injure the posterior wall of the trachea nor to catheterize the
esophagu^

As a fist resort, tracheotomy and catheterization through the
wound may be required. It is only required in most exceptional
cases. ^

Risks Attending Artificial Respiration. — Injuries, as apo
plexies ; Schultze's method may injure the spine ; hemorrhagic
effusions in the pleurae and lungs ; rupture of the air-vesicles in
insufflation ; the trachea and larynx may be injured ; the lung
may be punctured if the clavicle is broken.

After-treatment of Asphyxia Neonatorum. — A child deeply
asphyxiated and revived with difficulty will, more likely than
not, die within forty-eight hours of birth. It should be carefully
watched, therefore, for at least two days, in order to detect rapid
respiration, feeble heart-action, and evidence of intracranial dis-
turbance. It is'^a good practice to administer routinely to such
children ^\q drops of brandy and a drop of tincture of digitalis
in hot water, every four or every two hours, to keep them
swathed in cotton -wool, and possibly to surround them with
hot-water bottles or bags, if their vitality is low.

DISEASES OF THE NEV-BORN INFANT.

Diseases of the Lungs. — Atelectasis. — The causes are not
known. Sometimes it may be due to obstruction of the air-
passages, as by an enlarged thymus, a clot of blood, curd of
milk, etc.

The diagnosis is usually not made during life. Dullness on
percussion might be detected on one side if the atelectasis were

^ 1 was ()l)lin;c(l to H'sort to tliis treatment in a case of face presentation with
such distortion of the neck that nioulh-to-niouth insutllation and catheterization of the
larynx were im])os>il)le. Tlie cliild was kept alive for an hour, but would make no
attempt at respiration.

DISEASES OF THE NEW-BORN INFANT. 809

unilateral. The respiration is accelerated and imperfect. There
is an absence of fever. The symptoms are present at birth.

Pathological Anatomy. — One lung is found shriveled up, is
not crepitant, and sinks when placed in water.

The prognosis is necessarily grave.

Treatment. — If the diagnosis is made, gentle insufflation of
the lung with a catheter might be attempted.

Syphilis of the Lung. — The diagnosis may be made by a his-
tory of syphilis in the parents, by the signs of fetal syphilis,
together with the cyanosis and physical signs of pneumonia.
The temperature is very low, suggesting the use of an incu-
bator. Treatment, however, is of no avail, the child usually
dying within twenty-four to thirty-six hours.

Pathological Anatomy, — An enormous overgrowth of connec-
tive tissue is found, compressing the blood-vessels and diminish-
ing the capacity of the air-vesicles. As some air has entered
the lung, a cut-oflF portion never sinks, but does not float
buoyantly. The ** white pneumonia " of syphilitic infants is
rare. It is the result of proliferation, desquamation, and fatty
degeneration of the epithelial cells in the lungs, giving the latter
a white appearance, and distending them so that the thoracic
cavity is well filled out and the lungs bear the imprint of the
ribs. Respiration is impossible.

Septic infection of the lungs is rare. It is the result of inspi-
ration of septic matter from the vagina or from the decomposition
of inspired blood-clots or vaginal discharges.

Tuberculosis may be caused by mouth-to-mouth insufflation
on the part of a tuberculous person.

Pneumonia of the new-born is usually caused by the inspiration
of maternal discharges, resulting from intra-uterine respiratory
efforts when asphyxia is threatened.

Pneumonia arising from this cause develops about twenty-
four hours after birth, in a child apparently healthy, the tempera-
ture at this time beginning to rise and the respiration growing
more rapid. Cough, although a variable symptom, is occasion-
ally incessant. The child is restless, refuses the nipple, is
cyanotic, at times gasps for breath, and there may be dullness
over one or both lungs. The diagnosis can not always be made
by the physical signs ; only a small patch may be involved.
There is usually a history of dystocia. When a new-born infant
has a high temperature, septic infection or pneumonia should be
suspected as the most probable causes of the fever.

The prognosis is grave.

The treatment should consist of stimulation — gr. \i^ to J^
carbonate of ammonium in 3SS— jj mucilage of acacia every four

8 I O THE NE W-BORN INFANT.

hours if it does not irritate the stomach. Tincture of digitalis,
in drop doses, should be given every two or four hours. A
mustard-bath once, twice, or thrice daily ^ is an extremely im-
portant item in the treatment. A cotton jacket should be applied.
The mother's milk should be drawn from the breast and fed to
the infant from a medicine dropper in small quantities every
two hours ; a few drops of brandy may be added to it.

The pathological anatomy shows the features of catarrhal
pneumonia. A cut-off portion of the inflamed lung usually
sinks in water.

Pulmonary apoplexy is a rare accident in young infants, the
result of severe straining in crying or coughing. There is
hemoptysis, the quantity of blood lost usually not being very
great, though it stains the front of the dress and alarms the
child's caretaker exceedingly. The prognosis is favorable.

Syphilis of New-born Infant. — Symptoms. — The child is
often ill-developed and ill-nourished, but the characteristic signs
of the disease do not usually appear before four or six weeks.
In the order of their diagnostic value these signs are :

Coryza syphilitica. The discharge from the nose is irri-
tating to the upper lip, and frequently produces crusts and even
ulceration.

Maculopapular syphilide ; roseola, especially marked on the
heels ; cutaneous papules and mucous tubercles ; rhagades oris
et ani ; pemphigus ; cutaneous ulcers ; paronychias ; pseudo-
paralyses of extremities, due to infirm connection between diaph-
ysis and epiphysis, or to painful periostitis which inhibits motion ;
hemorrhagic diathesis ; bone diseases ; fever ; disease of the
testicles, which are enlarged from the overgrowth of connective
tissue.

Treatment. — The best results are obtained from the internal
use of calomel with chalk or soda, -^ of a grain given twice a
day, gradually increasing the dose. Should vomiting or diarrhea
occur, mercurial inunctions must be employed, rubbing a piece
of mercurial ointment as large as the end of the little finger on
the child's abdominal binder every other day.

This treatment should be kept up intermittently for months,
being replaced from time to time by tonics, as drop doses of
syrupus ferri iodidi. The child's food requires careful attention.

Prognosis. — If the child is well nourished by its mother or by
a wet-nurse, the prognosis is very good, so long as some inipor-

' The bath is made as follows: Three lar^e pitcherfuls of water at loo° F., anti
a tahlespooiiful of mustanl ; allow tlie child to remain in the bath for five minutes,
or until the tempt rature of the latter falls to 95°, when the infant should be removed
and wrnjiped, undressed, in a warmed blanket, in which it remains for a half hour.

DISEASES OF THE NE IV BORN INFANT, 8l I

tant internal organ is not seriously affected. In artificially fed
children the prognosis is unfavorable. The wet-nurse is liable
to be infected, and she should not be ignorant of her danger.

Mastitis. — Four days after birth the breasts in both sexes
contain colostrum, which has disapf)eared by the twentieth day.
During this period there may occur in the breast of the child
pathological processes like those in the breast of the puerpera.
The breasts may enlarge and become painful ; the skin over
them may be an angry red ; the secretion may be much increased,
so that the milk runs out in a stream, and even a mammary ab-
scess may develop.

Treatment. — The nurse must avoid squeezing the glands.
Cooling lotions should be applied, and the skin should be oiled,
to relieve tension. If suppuration occurs, the abscess should be
incised without delay, as there is always a tendency for the
pus to burrow inward toward the pleura.

Specific or Essential Fevers. — Exanthemata. — The infant
may exhibit the exanthem at birth or may contract the disease
subsequently. The treatment is the same as under other cir-
cumstances.

Septic Infection. — Infection occurs through the umbilicus.
The most important treatment is the preventive (see Diseases of
Umbilicus). The infection usually occurs in the first two weeks
of life, but the symptoms may appear as late as the fourth week.

The Treatment of Certain Congenital Deformities. — Hare-
lip.— This deformity may prevent suckling ; if so, an immediate
plastic operation is indicated, which may be undertaken in the
first few hours of life.

The operation for cleft-palate is too serious to be undertaken
during early infancy. A rubber flap over the nipple of the bottle
may enable the child to suck. It can not nurse from the breast.

Supernumerary digits should be ligated and cut off. If they
are mere fleshy appendages, a thread may be tied around their
base, and they may be left to fall off.

In a tongue-tie the frenum should be snipped superficially
with blunt-pointed scissors, and then torn with the fingers to the
floor of the mouth. The child's head is placed between the
knees of the operator ; the two first fingers of the left hand are
inserted on either side of the frenum, to hold the mouth open
and to protect the tongue from injury.

Umbilical Hernia. — There are two varieties of this deformity.
In one, a knuckle of intestine covered by skin projects from the
navel. This degree of deformity is common, occurring in two
per cent, of infants. It is treated by a convex button, cork, or
hard-rubber compress on a strip of adhesive plaster, which

8 1 2 THE NE W-BORN INFANT,

encircles two-thirds of the child's body. This improvised truss
is renewed from time to time, and should be worn six months.
In the second variety there is an exomphalic condition, due to
defective development, the intestines protruding from the umbili-
cus covered only by amnion. An immediate plastic operation is
indicated even if the mass of protruding intestines is as large as
an apple. The results of this operation have been excellent.

Spina bifida is to be distinguished from the less serious con-
ditions— fibroma, myxoma, or lipoma of buttocks — and from
parasitic teratomata. In spina bifida a hardened patch is found at
the prominence of the tumor, due to the attachment at that point
of the Cauda equina.

Treatment. — Lay the tumor open, dissect out the sac, make
traction upon the latter, when the cauda equina will retreat into
the canal ; ligate with catgut the pedicle formed, and accurately
close up the wound with buried catgut sutures, with strict asep-
sis. The prognosis is not good. If the child survives the opera-
tion, it is not unlikely to die of hydrocephalus.

imperforate Rectum. — The anus and rectum should be exam-
ined immediately after birth in all cases. To avoid the danger
of fecal accumulation, inguinal or lumbar colotomy should be
performed. In simple cases with merely a transverse septum
between the anus and the rectum, a cruciform incision over the
imperforate anus is sufficient to open the rectum. The mucous
membrane of the bowel is then stitched to the skin of the anus.

Tectinic of lng:uinal Colotomy for Atresia Ani. — Make an in-
cision above and parallel with Poupart's ligament on the left
side ; deliver the distended sigmoid flexure ; put two stitches
through it, one on each side of the bowel, the threads running
parallel with one another and with the long axis of the bowel,
the two ends of each stitch entering and emerging from the
bowel -wall about a quarter of an inch apart ; incise the bowel
between the two stitches, pulling it well down below the abdom-
inal wound, to guard the peritoneal cavity from contamination,
as meconium and gas make their escape. Making the wound in
the bowel gape by pulling upon the ligatures through its wall,
a few interrupted sutures are passed through the bowel at the
site of the opening and the abdominal wall, fastening the two
together, l^^inally, the edges of the abdominal and bowel wound
are whipped together with a continuous catgut stitch, to prevent
hemorrhagic from the former. An anesthetic is not absolutelv
necessary. I have seen the infant nursing contentedly from its
mother's breast ^y^i minutes after such an operation. I^ater,
the rjctuni may be probed from above to determine the depth
of the incision nccessar\' to reach it from the anus.

DISEASES OF THE NEWBORN INFANT. 813

Nasal Catarrh (Snuffles). — Catiscs. — When the disease is
not syphilitic, it is due, usually, to faulty clothing or to drafts
of air. The crib should be protected, and the child should wear
a thin lawn cap until its head is covered by a growth of hair.

Diseases of the Mouth. — Aphths arc rounded, pearl-colored
vesicles seen in the mouth and on the lips. Washing the mouth
daily with a clean linen towel will prevent them. Boric acid, gr.
v-x to the ounce, as a wash, is curative.

In true thrush there is a coalescence of white spots, with an
areola of reddened mucous membrane. The disease is often seen
in hospital practice, or in infants whose hygienic surroundings
are bad. It is due to the presence of a parasite, the saccharo-
myces albicans.

Treatment. — Boric acid, gr. xvj-xx to 5j of honey. One-half
of a dram of this mixture is put in the mouth three or four times
a day. The associated symptoms of malnutrition, diarrhea, and
vomiting indicate attention to hygienic surroundings, to the
general health of the child, and to its diet.

In g:onorrheal stomatitis there is violent inflammation of the
oral mucous membrane, due to the presence of gonococci.
Cleanliness and mild disinfection of the mouth with boric acid
solution will effect a cure. The disease is rare. I have seen
but one case in all my hospital services.

Subling:ual cysts are probably the result of the occlusion of
the duct of a submaxillary gland. The cyst appears in the first
few days after birth, and may reach such a size as to displace the
tongue and to interfere with sucking. The treatment consists of
puncture of the cyst, which does not return.

Colic, Diarrhea, Constipation. — Colic always indicates a
careful attention to diet. Medicinally, gr. j of pepsin may be given
in 1^ of hot water, with a few drops of brandy or gin. Milk of
asafetida, gtt. xx-xl, or soda-mint, 3J, may be used, and a spice-
plaster may be applied to the abdomen.

Diarrhea indicates almost always some error in the diet.
Frequent serous movements, draining the child's strength and
demanding a remedy, may be checked with the following :

R . Acid, sulphuric, aromat.,

Tinct. opii camph., aa gtt. iv.

One dose, not to be repeated.

Constipation. — In simple cases a dose of castor oil (3J), the
soap-stick, a glycerin suppository or injection (gtt. xv-xx in fgj
of water) suffice, or the following may be used :

B . Calcined matrnesia.

Sugar of milk, of each 7>^ grains.

8 1 4 THE NE WBORN INFANT.

For chronic constipation the daily injection of warm soap-
suds (fsij) by a soft-bulb rubber ear-syringe is least harmful.

Medicinally, the treatment may consist of a piece of flake
manna in each bottle of artificially fed children ; the administra-
tion of ten drops of the syrup of figs, with two to four drops of the
fluid extract of cascara ; a pinch of salt in the bottles ; the addi-
tion of Mellin's food, and daily abdominal massage ; the addition
to each bottle of milk of two to four grains phosphate of soda ; an
increase in the proportion of cream ; Tarrant's Seltzer Aperient
(ten grs.) in the milk ; a little milk of magnesia, added to one or
more bottles or given in water to a nursing baby.

Intussusception. — In a case in the University Maternit>% the
child died forty -eight hours after birth. The symptoms began in
the first twenty-four hours ; the child passed blood and mucus
by the bowel, developed high fever, and vomited incessantly.
Postmortem examination showed the intussusception in the
ileum ; the bowel above was much distended ; below, inflamed
and very dark in color for a couple of inches.

Skin Diseases. — Qum, a sort of acne, is due to the irritation
of the skin by the atmosphere and the clothing. It is exceed-
ingly common.

Treatment. — Cleanliness, proper clothing, and some simple
ointment, perhaps as a salve to the mother's anxiety as much as
to the infant's skin.

Furuncles are likely to be small and numerous. The condi-
tion is an exaggeration of gum, with enlargement and suppura-
tion of the pimples.

The diet and hygienic surroundings should be investigated.
The small boils may be washed twice daily with a solution of
boric acid, gr. xv, and resorcin, gr. iij-f^j, and boric acid
ointment, 5J-5J, ung. aq. rosae, may be applied. The boils may
be opened with a needle when they come to a head.

Simple acute pemphigus is ver)^ rare. From the second day
to the fourth, fifth, or sixth week, vesicles the size of a pea to a
quarter- or half-dollar appear indifferently over the whole body,
except the soles of the feet and the palms of the hands. The
disease lasts from twelve to fourteen days, without manifestation
of constitutional disturbance.

It is contagious, and may be carried by the nurse or be com-
municated to a mother or nurse. It disappears without treat-
ment. The specific micro-organism, it is claimed, has been dis-
covered.

Syphilitic pemphigus usually begins /";/ utero, and the child is
born with the vesicles upon it, the soles of the feet and the palms
of the hands being most often affected. The disease is associated

DISEASES OF THE NEW-BORN INFANT. 81$

with marked evidence of malnutrition and constitutional disturb-
ance, and yields only to specific treatment.

Ophthalmia Neonatorum. — Symptoms. — True ophthalmia
is the result of the infection of the conjunctivas by gonococci.
Usually after twenty-four to forty-eight hours the eyehds are
edematous and puffed out, and between them there appears a
seropurulent discharge, which soon becomes greenish -yellow
pus. When the lids are separated, the conjunctivae are seen to
be red and velvet-like in appearance, and later the cornea may
lose its epithelium, become glazed, ulcerate, and be perforated.

Treatment, Prophylactic. — The best preventive treatment is
the Crede method. As soon as the head is born, warm water is
dropped in the eyes. When the delivery is completed, the eyes
are again cleansed with warm water, followed by one or two
drops of a ten-grain solution of nitrate of silver to the ounce,
which is then washed out with salt solution.

Curative. — The eyes are cleansed every hour, day and night,
with a concentrated solution of boric acid. Cold compresses
are kept upon the lids. Morning and evening a drop of nitrate
of silver, twenty grains to the ounce, may be dropped in the eye,
followed by irrigation with salt solution. If only one eye be
affected, the other should be carefully bandaged with a pledget
of lint to protect it. A drop of a weak solution of atropia is
occasionally required. If possible, the case should be placed
under the care of an oculist. The author invariably refuses to
accept the responsibility of treating such a c3se. The mouth,
the nose, and the ears of a new-born infant may be the seat of
inflammation from gonorrheal infection.

There is frequently a subacute conjunctivitis after birth,
often affecting one eye alone, and yielding to the mildest treat-
ment, or disappearing spontaneously. The inexperienced phy-
sician not infrequently mistakes this innocuous inflammation for
ophthalmia, and by the injudicious energy of his treatment con-
verts a mild into a very severe conjunctivitis. I have seen per-
manent opacity of the comeae from the unnecessary use of
nitrate of silver in such a case. The severest possible inflamma-
tion, ending in total blindness, has resulted from the injection of
sublimate solution in the vagina during labor, the corrosive sub-
limate gaining access to the child's eyes and causing inflammation
and perforation of the comeae.

Hemophilia is an inherited pathological disposition to bleed
from apparently normal or slightly injured surfaces. The manner
of transmission is peculiar ; it is always through the mother to
male children, who do not transmit it. The female children show
no evidence of the disease, but transmit it. The cause is not

8 1 6 THE NE W-BORN INFANT.

known, and it manifests itself throughout Hfe. Treatment is of
no avail. It should be remembered that a hemorrhagic diathesis
is sometimes due to syphilis, and in such cases specific treatment
is of value. I have seen a hemophilic infant bleed to death from
its conjunctivae, incessantly weeping tears of blood, and another
lose its life from hemorrhage following a superficial abrasion
under the tongue.

Icterus. — There are two classes of cases :

In the first the jaundice is slight in degree. The face and
breast only are affected. This grade of jaundice is very com-
mon, the majority of children manifesting it.

The catise is said to be hepatogenic. The very small com-
mon biliary duct fails to empty into the bowel the excess of bile
produced by the liver. The discoloration disappears a few days
after birth, and the condition usually requires no treatment.
Fractional doses of calomel may be given if the child's digestion
is impaired, or if the jaundice is deeper than common.

In the second variety the whole body is jaundiced. The
urine and feces are discolored, and may contain blood. This
variety is decidedly rare, and is a manifestation of grave systemic
derangement, usually general septic infection.

Causes. — This kind of jaundice is said also to be, as a rule,
hepatogenic. It is seen in Buhl's and Winckel's disease, in
atresia of the bile-duct, and in polycystic disease of the liver.
In streptococcic infection of the blood-current producing disinte-
gration of the blood, the jaundice, I believe, is in part hemato-
genic, resulting from a disintegration of the blood-corpuscles.

The prognosis of the malignant variety is extremely grave.
The result is almost invariably fatal.

Cyanosis was once thought to be synonymous with congeni-
tal heart disease. The laity still regard a *' blue baby " as one
with a defective heart.

The eauses of cyanosis, in the order of their frequency, are :
pneumonia (often syphilitic), premature birth, asphyxia, atelec-
tasis, degeneration of the blood, malformation of the heart and
blood-vessels, interference with the function of the nerves of
respiration, malformation of the respiratory tract, congenital
pleurisy, and partial occlusion of the trachea.

Congenital heart affections may result from intra-uterine
endocarditis, as stenosis of the right and left auriculoventricular
orifices, stenosis of the aortic and pulmonary orifices, and insuffi-
ciency of the valves. Or they may be the result of defective
development, as patency of the foramen ovale, atresia of the
pulmonary artery, stenosis of the conus arteriosus, and defects
in the vx*ntricular septum.

DISEASES OF THE NEWBORN INFANT. 817

A child with congenital heart disease must be managed with
extraordinary care. Exposure to cold is particularly danger-
ous, as there is a tendency to pulmonary congestion and pneu-
monia. Artificial heat may be necessary ; malnutrition must be
combated ; heart tonics may be required. The prognosis is
relatively favorable. Compensation may often be secured in
apparently the most unfavorable cases.

Diseases of Umbilicus. — Septic infection. — The ulcer on an
infected umbilicus is covered with a grayish, diphtheritic mem-
brane, has a reddened areola, and the local inflammation leads
to general infection. An acute, high fever in a new-born infant
suggests septic infection or pneumonia. The latter may be sep-
tic. The so-called Buhl's and Winckel's diseases, with fatty
degeneration of the organs, icterus, cyanosis, and hemoglob-
inuria, are merely the result of streptococcic infection of the
blood-current.

Treatment, Prophylactic. — The ulcer should be exposed at the
daily bath, cleansed with soap and water, and dressed with sali-
cylic acid, I part ; starch, 5 parts. An aseptic ligature should
always be used to ligate the cord at birth, and the daily dressing
of the cord with fresh salicylated cotton should be carefully
carried out with clean hands until the cord drops off.

Curative Treatment. — The ulcer should be touched with a
solution of bichlorid of mercury, i : 500, or with nitrate of silver
solution, 3J-f5J. It should be thoroughly irrigated and dusted
with salicylic acid and starch, and covered with salicylated
cotton.

Umbilical fungus is usually an overgrowth of granulation
tissue. It projects in a mass like a strawberry from the navel.
It should be cauterized with a solid stick of nitrate of silver,
whereupon it promptly melts away. In about one-fifth of the
cases cauterization fails, the tumor is more solid in feel, and is
found, on microscopic investigation, to be the remains of the om-
phalic duct. This kind of umbilical fungus is called an entero-
teratoma. It should be ligated and cut off. The stump of the
cord may persist, unchanged, almost indefinitely, covered with an
angry, red layer of granulation cells, or a spur of well -organized
connective tissue may project from the umbilicus. In such cases
there is a small supply of blood to the cord in spite of the liga-
ture. The projecting mass must be cut off. I have been obliged
to amputate the persistent stump of a cord on the sixteenth day.

Omphalitis is a peculiar inflammation of the umbilicus and
surrounding structures, in which the abdomen becomes conical
in shape ; the skin and subcutaneous connective tissue are hard,
red, and infiltrated. It is always septic in origin. It requires dis-

8 1 8 THE NE VV-BORN INFANT,

infection of the umbilicus, poultices, and early incisions, with
stimulants and supporting treatment. A later stage of the in-
flammation is gangrene. The prognosis is very grave. It is
difficult to avert general systemic infection.

Inflammation of the umbilical vessels is always due to septic
infection, and invariably leads to systemic infection, which is
commonly fatal.

Hemorrhag:e from the Umbilicus (Omphalorrhagia). — The bleed-
ing may come from the cord or from the umbilical ulcer. It
may be primary, from careless ligation of the cord ; or second-
ar>% after the cord drops off*. The vessels of the cord close from
the placental end inward, and the hypogastric arteries may be
patulous after the cord drops off", when increased blood-pressure
or handling the ulcer may bring on hemorrhage. The mortality
of this accident is computed at seventy-six to eighty-three per
cent.

Treatment. — In primary hemorrhage the cord must be
promptly re-ligated. In bleeding from the umbilical stump, if
the bleeding vessels are seen, they should be ligated. Usually,
it is impossible to isolate the bleeding vessels. In such cases
the hemorrhage may be controlled by Monsel's solution and
pressure by liquid plaster-of- Paris poured into the navel, where
it ** sets,'* or by successive layers of powdered bismuth, with
gauze and collodion. As a last resort, the abdominal wall
around the navel should be transfixed with harelip pins or ordi-
nary large -sized needles, and a figure-of-eight ligature should be
applied under them. If there is sufficient stump of the cord left,
it should be drawn out and transfixed with two pins or needles
and ligated below them. I was able to check a hemorrhage in
this way several days after the cord had dropped off". If this is
impossible, one pin may suffice ; it should transfix the abdominal
wall just below the umbilicus, so as to occlude the hypogastric
arteries. Before inserting the pin the abdominal walls should
be compressed and rolled between the thumb and forefinger to
get rid of coils of intestines. Should the hemorrhage continue,
it can be controlled by a pin above the umbilicus to occlude the
umbilical vein.

Tetanus of the new-born is the result of the entrance of
tetanus bacilli through the umbilicus. The disease in temperate
climates occurs almost exclusively in hospitals. It is usually
fatal, the death-rate being over ninety per cent. The treatment
should always include an immediate and a thorough disinfection
of the navel.

Melena, or gastro- intestinal hemorrhage, is an extravasa-
tion of blood into the stomach and intestines, occurring most

D/SEASES OF THE .VEIV-BORX JXFA.VT. 819

often in the first few hours of life. Duodenal ulcer, some con-
genital defect increasing intra-abdominal blood -pressure, intus-
susception, or hemophilia may be the cause. The child may
vomit bright, unaltered blood, or the vomit may be " coflee-
grounds " in character. The blood from the bowel is black in
color, and is mixed \vith meconium, hence the name melena.
It is to be carefully distinguished from the vomiting of blood
derived from a fissured nipple in the mother and ingested with
the milk-. In melena the infant shows unmistakable .symptoms
of internal hemorrhage.

Treatment. — Gallic acid, gr. ij. may be given everj' hour.

Fig. 618.— AUesia of llie ureler : A, Kidney ; B, urelcr ; C, blnddtr (aullior
iu L'niversily Mmemily).

Ergotin hypodermatically, an ice-bag to the abdomen, and hot
bottles to the flanks and thighs. Stimulation may be required.
The mortality, in spite of intelligent and energetic treatment, is
fifty per cent.

Bloody discharge from the genitalia of female children is
not very rare. It shows an activity of the sexual organs anal-
ogous to the breast changes in the new-born. The condition is
not dangerous, and requires no treatment. The blood comes

THE .VEir-SOR.V IXfA.VT.

iL-n^s -ike the menstrual discharges — in fact, tlu- dii-
a :rjc menstruation, as has been demonstraioil in
; examinations of infants who died from inttrcuirent
I: appears three or four da\'s after birth, and lasts
divs.

death of apparently healthy children is an accident
r- : -r/K^-cntly liemanding an explanation by the attcndi-nj

A=: — .^ iTx .-.viSiS may be found iiir/vi/ij^ by the im-r!i,r,
iC'~.ier;a!'y ^r intentionally. I have seen Hw cases. In imt
x" tJK rti^-TLs ■>:' the Rei;istrar-<;reneral of Kngland. there was i
rec.ri :'' '.}X ;,ises. the majoritj- occurring on Saturday ni|;bl 1

."■:/.■ L-v.'. — M"s; commonly pneumonias. ap«plexie<. more
rarxly ;*r .Tati ^r. or :ntas>usception of the bowels, rupture of a
"..i.--i .-.^v..;*, r A:;y i--:' the diseases previously described, which

luring life.

/ .«/.(;

iif thrvius o

mpt'rtiiHt iiiUrmtl organs, as atresia

ilkation of the New-born. — In administering medicini t>i
;.- "rv-r-. :r.:Ar::, the physician should remember its peculiar
•T .■ ■■ ■-;;.-■; and its tolerance of some other remedies.
; r''.l:.i-.r^ ,=,re some of the drugs and their dose? rc-
.- :>; rr^: !>-r weeks oi life : Opium, only as pa^|,'oric.
. • : - --.e drops in one dose, not rtf-catcii ; mercur>-. alw.ijs
~. ^3 :^ t ^'- - castor oil. 15 gtt. to 3j ; nitrate of silver,
^r . ;v.\*;n, ^r. j-ij ; gallic acid, gr. ss— ij, etc.

INDEX.

Abdomen, appearance of, in pregnancy,

195
changes in size and shape of, in preg-
nancy, 192
palpation of, in pregnancy, 200
Abdominal binder in postpartum hem-
orrhage, 539
muscles, contraction of, in labor, 306
diastasis of, in labor, 570
in puerperal state, 632
pad after labor. 313
palpation, diagnosis of position of fetus

in labor, 350
in pregnancy, 200
pregnancy, 259

clinical history of, 265
death of fetus in, 271
symptoms of, 278
section, exploratory, for puerperal sep-
sis, 694
for mterstitial pregnancy, 281
for tubal pregnancy, 279
in puerperal sepsis, 685
tumors, putrefaction of, 713
walls, change in, in pregnancy, 186
Abortion, 243
after-treatment of, 257
appearance of ovum after, 248
causes of, 243
clinical history of, 247

phenomena of, 248
diagnosis of, 251
duration of, 248
frequency of, 247
from abnormal positions of the uterus,

246
from alterations of the maternal blood,

246
from anemia, 176
from cholera, 161
from chronic endometritis, 176
metritis, 176

poisoning of mother, 177
from coughing, 245
from diffuse hyperplasia of decidual
endometrium, 144

Abortion from emphysema of lungs, 239
from heart disease, 236
from injuries of mother, 242
from irritable uterus, 243
from maternal diabetes, 177
from metritis, 215
from overdistention of uterus, 247
from placenta pnevia, 530
from prolapse of uterus, 246
from retroflexion of uterus, 246
from typhoid fever, 1 61
from vomiting, 245
hemorrhage in, 248
in cholemic convulsions, 246
in chorea, 245
in eclampsia, 245
in epilepsy, 245
in hydramnios, 247
in hysterical convulsions, 246
in multiple pregnancy, 247
in retrodisplacement of the pregnant

uterus, 212
induction of, 719

indications for, 719

in nephritis, 229

in pneumonia, 617

methods of, 720
inevitable, diagnosis of, 25 1

treatment of, 255
missed, 258
pain in, 248
prognosis of, 253
threatened, diagnosis of, 25 1

treatment of, 254
treatment of, 254
tubal, 272
Abscess, ischiorectal, 714
mammary, 657

in pregnancy, 221
of Bertholin's gland, obstruction of

labor by, 490
postmammary, 657
suburethral, in pregnancy, 21 7
Acanthopelys, 453

Accessory corpuscle of spermatozoon, 65
Accidental hemorrhage, 534. See Hem-
orrhage

Accouchement fore*

Acelabuluni. fracture
Acetonuria in pregna
After binli. See /■/
Adct-eoming head.

n ecUmpsia, 5
of. 457
ncy. 231

deliveT of. by

I
for-

ccp.. 705

Mauriceau's method, 763
Prague'iiuethoi), ;b;
Wiegand's me[h«d. 763
Af(er-[>Bin>. 32S

Albuminuria an indication for inducing
abonion, 719
from death of fetus. 1 74

<leve1opinent of. 92

Amniutic Ivnds. fotmalio
fluid. See Lifiior jm,

' Arms, delivery of, after podahc VH?iiio.

I .Arthritis in puerperal stale. 629

I Articular rheumatism of felos. 16:

I .\rtifictai dilatation of the cerrical canal,

I 74S

I feeding of infant. 71)6

fofxl, preparation of 7^
' TesDJralion of new boni iafuit. S07
Schulize'; meibod, S37
Ash of human milk. 796
Asphyxia livida, Soi>
neonatorum. tk>o

afier-treaiment of, SoS
causes of, 806
treatment of, 806
of new-bom child, 806
pallida, S06
Asthma in preenancy. 239
.Atelectasis of new bom infant. SoS
Atresia ani of newborn, treauneni nt

Sl2
of va)^in.i,ob$lructionof labor bi, 489
Atrophy nf decidu.-B, 150
Auscultation, diagno>Js of portion ri
fetus by, 352
in diagnosis of pregnanct, lOl
Auto infection in puerperal sepiis, 672
.-\uvaril incubator, 793

pcrniti.m:s. in pregnanty. 238

B*BY-CinTHES, 347

pucri>etal. 588

Baby's basket. 34S

Aiic-tliciic* in labor, 303

Bacillus aerogenes capsulstos in

Ane„r>>,n in pregnancy, 138

petal sepsis. 671

Ankylu^is in fetus. Km

fielidus ia puer[*ral sepsis. 670

of pelvic (oinl*.45'>

pyocyancus in puerperal sep^t.

Annular pLufiiLi. 120

Bacteria, pa, sage of, from uHth

fetus. 156

nlel,

llacleriolt^v of the vagina, 661^67

nu..-„,„.,nen.of.41I

Bag of waters. 292

of.

Ballotlemeni. 3oz

Bandl.rineof.iSj, 354.544

of pdvi.. 22

Barnes bag« for anilici^l dilataiit

cervical canal. 74S

Anus v;,^iii;.li-, i.|.-i,mli,in oflaborbv,

in ineitia uteri. 4Q4

4S'.

in jilaccnta pr.-evia. 533

veMilHilaii>, ,.l.-t.i..li..n of labor

by.

in treatment of hematoma, 606

J.S,,

Ilartholin's glands. 45

Aplith,i-..|-,u.v.l,>.n,, ,SIJ

abscess of. obsiniction of lain

Ap.i,.U.vifMnpr,sna„cy.i32
in pueri.cral >Mie. 040
l>nlmon,tT^..liu.« hnrn.Slo

490
Basiotribe. Tarnier's. 770 771
Uaudelocque-s diameter. 411

Appeniiicilii in ('ce);ii.iiii v. J26

method of cephalic version. 376

Appetite iiMHi'-l'-r-i-i.^if.j.U

Binder, mamman-. 346

Arbor vii.v .-f ni.-ri,., 4"

ohsietrical, 313

Areola pf prejiisii.-v. I'n

Bladder, changes in. in pregnuicj.

Ann»meniaiiunif..r l.d,..r, .199

diseases of. in pregnancy, 130

1.248

Avulsion of limbs of child in labor, Sq(
application of. 743

INDEX.

823

Bladder, irritability of, in pregnancy, 230

Blastomeres, 72

Blindness in pregnancy, 234

Blood, changes in, in pregnancy, 186

clots, retention of, puerperal hemor-
rhage from, 599

diseases of, in pregnancy, 238

in new-born infant, 791

tumor. See Hematoma

-vessels, diseases of, in pregnancy,

237 .
of pelvic organs, 32

of uterus, changes in, in pregnancy,
181
Bloody discharge from genitalia of new-
born female children, 819
Blot's perforator, 768, 769
Blunt hook, 748
Body-cavity, 73
Body of Rosenmiiller, 42
Boric acid in aphthae of new-born, 813
in cystitis, 639
in thrush of new-bom, 813
Bougies, graduated, for dilating cervical
canal, 749
Hegar's, 749
Bowels in puerperal state, 343

movements of, in new-bom infant,

790
of child, injury of, in labor, 805
Brachial palsy from injury during labor,

800
Brain, congestion of, in pregnancy, 232
diseases of, in pregnancy, 232
injury to, during labor, 799
Braun's cranioclast, 769

hook, 774
Breast-pump, 655

Breasts. See also Mammary glands
absence of, 641
areola of, in pregnancy, 194
hypertrophy of, 641
inflammation of, 656
in pregnancy, 194
sensations in, in pregnancy, 193
strise of, in pregnancy, 194
supernumerary, 641
Breech, extraction of, 745
by blunt hook, 748
by fillet, 747
by forceps, 747
manual method of, 745
presentation, 381. See Presentation y
breech
Brim of pelvis, 17
Broad- ligament pregnancy, 261
Bronchial catarrh in pregnancy, 239
Brow presentation, 378. See Presenta-
tion
Brown atrophy of myocardium in preg-»

nancy, 237
Bruit, uterine, 203

Buhl's disease, 817
Bulbs of vestibule, 45

Caked breast, 655

Calcareous degeneration of placenta, 124

of umbilical cord, 138
Calculi, vesical, complication of labor by,

505
in pregnancy, 231

Calculus, renal, in pregnancy, 230
Canals of Gartner, 41
Cancer, syncytial, 129
Caput succedaneum, 800
in flat pelvis, 426
in justominor pelvis, 431
Carcinoma of cervix uteri, obstroction of
labor by, 498
of utems a cause of puerperal hemor-
rhage, 600
syncytiale, 129
Cardiac nerve-storms, 240
Caries of pelvis, 459

of teeth in pregnancy, 221
Camncula; myrtiformes, 45, 208

enlarged, obstruction of labor by,
491
Cams, curve of, 24
Casein of milk, 796
Catarrhal endometritis, 147
Catheterization in puerperal state, 342
Celiohysterectomy, 781

and celiohysterotomy, choice of, 785
Cellular hypertrophy of placental villi,

120
Celom, 72

Centers of ossification as signs of matu-
rity of fetus, 86
Cephalhematoma, 802
Cephalic presentation. See Presenta-
tion
version. See Version
Cephalotribe, Hick's, 770
Cephalotribes, 771

Cervical canal, artificial dilatation of, 748
by Barnes' bags, 748
by forceps, 749
by graduated bougies, 749
by manual method, 749
by multiple incisions, 749
pregnancy of Rokitansky, 151
Cervicitis in pregnancy, 216
Cervix uieri, alterations in, in pregnancy,

185

atresia of, obstruction of labor by,

485
carcinoma of, obstruction of labor

by, 498
cicatricial contraction of, obstmction

of labor by, 486
circular detachment of, in labor, 555
dilatation of, artificial, 748

824

of, obstruction of labor

by, 49S
iDJorics 10. m laboi. 551
rigkii ' ■

Cnarean KClion. 779
indioliont for. 7S1
ID labor wiih coalTacIcd ptWa. 4S3,

Pottos melhod. 780. 781

pcisunonem. 779

Singer's method. 7S0. 7&4

varieties of. 7S2
Cn*alion of menstruilion ti > sigD of

pregniDct'. 191
Chunberleni Tectii, 72;
Cbild, new-born. See -I'-fi'i'ii™ infant
Chloasmata of pregnancy. 194, 242
Chloral in edimpjia. 5S0
in gal:

in rigiJity of
Chlotxionn in •

in lalur. 304
Cbolemii: convi
Cbolera of I'elu

\a pregnancy

>. 40-t

DOuIreponf s roelhod of. 758
Wrights method of. 758
Compact layer of ulenne deckjua. \i»
Compound prev^ntition. 516. Sec /Vf.

Concept ion.

average date of.

iflet mu-

. riaee

[ime when

mo^I likelv 10 oc.

mt. t>9

-tice!ephintia.-i.

165

defonnilie

. treatment of Si

Congestion 0

brain in preEn.incv, 2U

mi. 4S5

Conjugate di

uneter, false, of

list lies

c pelvis. 464

of pelvis
413

lagona . mcaso

rfincni

nanual mMbod. 414

f.4lt

true, measuremeni r.f. 4I3. 414

ConjimctiTiti

of new-bum, St

Connect ire ti

sue of pelvis. 2.S

of utem

. alleraiicns in.

in preg-

iSi

Conslipaiioii

n pregnancv. 1S7

tSS

of. 225

ofne«'-bon

Contracted ]>e

pelvis, flat.

4,!l

rally. "429. See P/.'v^

ilothins'of !iv« l.,>r!
Ci>oinf.>r hein»rrh..i
■D pernicious voinii
CocCTX. frsclure of, ii
CoffM -SruumU v,.niii

Conttaci
Cord, u

Lon-nng. IJ>1. 354, 544

ons. 576, .See also f./jw^.u

mbilical. 132. See UfiHIi.-al

late ligation of. 317
ligilion of. 318
prolapse of, 573
reposition of, 574
rupture of. 575
! Cords, coiling of. in twin labor, *20
i Corpus luieum. 62

of mensiruation, 62

of pregnancy, 63

' Cotyledons of placenta. iiS

Coughing, abortion fnim. 245

Cows' milk compared to hnoua, 79'

composition of. 797
Coxalgic pelvis, 475
Cranioclaal. 768, 769

INDEX.

825

Cranioclast, Braun's, 769

Hirst's, 769

Simpson's, 769
Craniopagus, 507
Craniotomy, 767

instruments for, 768

technic of, 771
Credo's method of expressing placenta,

of preventing ophthalmia neonato-
rum, 815
Curve of Cams, 24
Cyanosis of new-bom, 816
Cystic degeneration of chorion villi, 104
clinical history and diagnosis
of, 109

etiology and frequency of, I lo
pathological anatomy of, 107
treatment of, ill
endometritis, 148
Cystitis in pregnancy, 231
in puerperal state, 638
septic, in puerperal sepsis, 712
Cystocele, obstruction of labor by, 505
Cjrsts of amnion, 102
of placenta, 129
of umbilical cord, 138
ovarian, complication of labor by, 502

Davis forceps, 729

Death of fetus, causes of, in fetus itself,

178

referable to father, 178
detection of, 173
diagnosis of, 206
effect of, upon mother, 172
habitual, 175
in utero, 172
of mother, effect of, upon fetus, 171,

572
sudden, in labor, 571
Decapitation, 773

Decidua, diffuse hyperplasia of, 144
epichorial, 140

ovular, 140 •

placental, 140
reflexa, 139, 140
serotina, 139
uterine, 140

compact layer of, 140
glandular layer of, 143
spongy layer of, 143
vera, 139, 140
Decidure, 139
acute inflammation of, 149
atrophy of, 150
diseases of, 144
Decidual cells of Friedllnder, 140
endometritis, exanthematous, 149
hemorrhagic y 146

Decidual endometrium, diffuse hyper-
plasia of, 144
fragments, retention of, after labor, 592
Deciduoma malignum, 129
Deciduosarcoma, 129
Deformities of pelvis, 407. See Pelvis
Delirium of fever in pregnant women.

235
temporary, of labor, 235

tremens distinguished from puerperal
insanity, 235
Delivery of placenta, 314

postmortem, 573
Descent stage of labor, 293
Determination of sex, 87
Deutoplasm ol ovum, 60
De venter's method of delivering after-
coming head, 766
Diabetes, maternal, effect of, upon fetus,
177
mellitus in pregnancy, 232
Diagnosis of life or death of fetus, 205
Diagonal conjugate, measurement of, 413

manual method of, 414
Diameter of pelvis, anteroposterior, of
outlet, measurement of, 423
Baudelocque's, 411
diagonal conjugate, measurement of,

413

by manual method, 414

external conjugate, measurement of,

411
transverse, measurement of, 420

of outlet, measurement of, 422
tme conjugate, measurement of,

413*414
Diameters of fetal head, normal, 86

of pelvis, 22
Diarrhea in pregnancy, treatment of, 225
Diastasis of abdominal muscles in puer-
peral state, 632
Dicephalus, 507

birth of, 509, 511, 512
Diet in puerperal state, 340

regulation of, in pregnancy, 189
Diffuse peritonitis in puerperal sepsis, 698
Digestion in new-bora infant, 790
Digestive tract, changes in, in pregnancy

187
Dilatation stage of labor, 293
Dilators, Hegar's, 749
Dimensions of fetal head, 86
Diphtheria in puerperal state, 626

relation of, to puerperal sepsis, 716
Diprosopus, craniotomy for, 513
Dipygus, 508

parasiticus, 508
Direction of presenting part, anomalies

of, 365
Discus proligerus, 60
Dissecting metritis in puerperal sepsis,
697

Distortion of hrad during labor. Soo
Ddderlcin, vaginal bacilli of, 664
Uoulile promontory, 424

vagina. 450
D'Outrepont's method of coinhined vi

Dropsy of amnion. 96

of cliorion villi, loj
Dry I.ibor. 533
Ductus arteriosus, 83

omphaliciis, I33

DuMi

ess on |>crrus!iion of alidomen in

pregn-incy, 203
ion of pregnancy, eslimation of.

■ A, 576
n in, 245
liempiitrorciin.sSl

-s of. 576
■ ■ I. 5S0

chloral
chloiofotni
diaphoresis in, 579
dilTerential diagnosis of. 577
during lalior, 581
effect of. ,>n fclu,, 17I
frequency o(. 577
bol-air I'aih in. Sjg
morpliinin.579
nilMle of anivl in, 5S0
• - ■ • It of, sSl

oxygen
ptogno

i.Sto

Enibolisin of pal moD>ry artery in Ilia
S/l

pulmon.'uy. in pregnancy, 239
Embryo, development of, 74

in first month, 74

■n third monih, 79
Embryonal area, 7J

Embryolomy. 767
Emotion as a cause of puerperal bem
rhage. ^^1

death fTom.in labor, 572
Emotional fever in puerperal itale, 607
Emotions, maternal, influeocc of. npc

felu$. 169
Emphysema in pregnancy, 2J9

subcutaneous, in labor, 570
Encolpiiis in puerperal sei-sii. 696
Endocervicilis in pregnJncy, 216
Endochorinn. 1 04

chronic, as a cause of death ol frtt
176

cystic. 148

decidua |iolyposa or tuberosa, 140

decidualis, 124

exanthematous decidual, 149

hemorrbagic decidual, 149

in puerperal sepsis, 696

microbic <lecidual, 150

placentaris ^mmosa, 134

polypoid, 14b

purulent ilecidual, 150
Endometrium, decidual, diffuse h>pi
(ilasia of. 144
hyperplixsiic inflammation of. I.

involution of. 324
Entoderm. 71
Epichorial deciduB. 140
Epilepsy, nbonion in, 245

in pregnancy. 233
Eprsiolomy. 308
Epistaxis in parturition, 13S

in pregnancy, 23S
Epo6phoron, 42
Erysipelas in puerperal state, 613

of fellas, 159

relation of. 10 puerperal sepsis, 716
Erythematous rashes in puetpeial stil

Ectopic prei^ancy, 259. See E.xti.i-

Ecrema of ni]iplts in pregnniicy. 221
Edema of genitals after lalior. 590
of glotlii. in prcBnaiicy, 339

of vulva in prey nancy. Jl8
Etigar'n method of dilating os uteri. 749
Effective conjugate di.imelcr of spondy-

lolislhesic pelvis, 464
Egg-corcU. ;;,.
Elephantiasis, c^inyenitnl cystic. 165

Evist

I. 774

Evolution, spontaneous. 394
Ejantheraat.T of new bom, 811
Exanihematou!i decidual eodonKtrili

Exostoses of pelvis. 453
Expulsion, forces of, 354

stage of labor, 293
Expulsive force of labor, cxceuin po*

>t fetal head, a

Hof.jl

IXDEX.

S27

Extension of fetal head in face presenta-
tions, 372
in labor, 360
External conjugate, measurement of, 41 1

genitals, development of, 42
Extramedian engagement of head, 428
Extra-uterine pregnancy, 259

advanced, 281

changes in uterus and vagina in,
261

classification of, 259

clinical history of, 260

diagnosis of, 278

etiology of, 260

frequency of, 259

prognosis of, 278

symptoms of, 274

terminations of, 267

treatment of, 279
Eyesight in new-born infant, 791

Face, appearance of, in pregnancy, 194
injuries of, during labor, 803
presentations, 370. See Presentation,
face

Fallopian tubes, anatomy of, 50

False corpus luteum, 63

Fat of human milk, 796

Fatty degeneration of heart in pregnancy,

237
of placenta, 121

Feeding of new-born infant, 795

artificial, 796

Female pronucleus, 69

sexual organs, development of. 39

Femora, luxation of, effect on pelvis of,

477
Fertilization of ovum, 69

Fetal head, dimensions of, 86

structure of, 356
movements, auscultation of, 204

in pregnancy, I93

palpation of, 201
pelvis, 432
syphilis, 15 1

diagnosis of, 153 -

manifestations of, 152

prognosis of, 153

treatment of, 155

Wegner's sign of, 1 54
traumatism, 167
Fetation, multiple, 89

abortion in, 91

acardia in, 91

fetus papyraceus in, 91

frequency of, 89

hydramnios in, 91

placenta in, 90
Fetus, accidents to, 573
alterations in maternal blood that are
fatal to, 176

Fetus, anasarca of, 165
ankyloses in, 166
articular rheumatism of, 1 62
cause of death of, in itself, 178
cholera of, 161
circulation of blood in, 82
conditions of uterus which interfere

with development of, 175
death of, diagnosis of, 205

effect of, upon mother, 172

from causes referable to father, 178

in uteroy 1 72
development of, 74

in eighth month, 81

in fifth month, 80

in first month, 74

in fourth month, 79

in ninth month, 81

in second month, 78

in seventh month, 80

in sixth month, 80

in tenth month, 81

in third month, 79
diagnosis of life or death of, 205
diseases of, 151

effect of chronic diseases of mother
upon, 177

of chronic poisoning of mother upon,
178

of death of mother upon, 171, 572

of eclampsia upon, 171

of excess of urea in maternal blood
upon, 177

of maternal diabetes upon, 177

of maternal nephritis upon, 177
erysi|)elas of, 159
fractures of the bones of, in utero^

166
habitual death of, 175

diagnosis of cause of, 179
preventive treatment of, 180
infectious diseases of, other than syph-
ilis, 156
influence of icterus gravidarum upon,
170

of maternal emotions upon, 169

of maternal fever upon, 168
intestinal invagination in, 166
luxations in. 166
malaria of, 160
malformations of, obstruction of labor

by, 509

mature, 85

general appearance of, 87

length of, 86

weight of, 85
measles of, 158
non-infectious diseases of, 162
overgrowth of, obstruction of labor by,

505
pwipyraceus. 9 1

rachitis of, 163

828

INDEX.

Fetus, recurrent fever of, 162
scarlatina of, 159
septicemia of, 161
sex of, diagnosis of, 208
signs of maturity of, 85
syphilis of, 151
syphilitic infection of, 151
temperature of, in uterOy 84
traumatism of, 167
tuberculosis of, 160
tumors of, obstruction of labor by, 512
typhoid fever of, 161
variola of, 158
yellow fever of, 162
Fever in puerperal state, emotional, 607

from cerebral disease, 612

from constipation, 610

from exposure to cold, 609

from reflex irritation, 610

non -infectious, 607

syphilitic, 614

with eclampsia, 613
maternal, influence of, upon fetus, 168
Fibrofatty degeneration of placenta, 121
Fibroid of uterus, obstruction of labor by,

498
Fibroids in puerperal state, 599
Fibromata of uterus in pregnancy, 215
Fibromyxomatous degeneration of cho-
rion, 112
Fibrous degeneration of placenta, 121
Fillet-carrier. 746, 747

extraction of breech by, 747
Fimbriae of oviduct, 53
Finger nails, loosening of, in pregnancy,

242
Flat pelvis, non-rachitic, 431

rachitic pelvis, 441
Flexion of fetal head, 360

abnormalities of, 364
Food-yolk of ovum, 60
Foramen ovale, 83
Forceps, 722

application of, 733

axis-traction, application of, 743

Davis', 729

dilatation of cervical canal by, 749

Hirst's, 728

historical sketch of, 722

Hodge's, 727

in after-coming head, 765

in breech presentation, 747

in labor with contracted pelvis, 482

in occipitoposterior positions, 742

in transverse positions of head, 742

indications for application of, 731

introduction of, 733

Levrel's, 726

locking of, 738

mortality from, 745

Palfyn's, 725

position for, 733

Forceps, Poulet's axis- traction, 730

preparations for application of, 733

Simpson's, 728

Smellie's, 726

sterilization of, 733

Tamier's axis-traction, 730

traction on, 739

uses and functions of, 731
Forces of expulsion, 354

of labor, anomalies of, 401

of resbtance, 354
Fossa navicularis, 44
Fourchet, 44

Fracture of limbs of child during labor,
804

of pelvis, 456

of skull during labor, 800
Fractures in utero, 166
FriedlSnder, decidual cells of, 140
Fundus uteri, height of, as an indication

of duration of pregnancy, 205
Funic souffle, 203
Funis. See Cord^ umbilical
Funnel-shaped pelvis, 432
Furuncles of new-born, 814

Galactocele, 658

Galactorrhea, 649

Galbiati's knife, 776

Gangrene of vulva, obstruction of labor

by, 491
GS.rtner, canals of, 41
Gastro-intestinal hemorrhage in new-
born, 818
Gavage of premature infants, 793
Gelatin of Wharton, 132
Generative organs, nerves of, 32
Genital cord, 40

eminence, 42
Genitalia, diseases of, 210
Genitals, external, development of, 42

internal, development of, 39
Germinal spot of ovum, 60

vesicle of ovum, 60
Germ-yolk of ovum, 60
Gestation. See Pre^^nancy
Gingivitis in pregnancy, 221
Glands of clitoris. 45

of Montgomery, 334
Gland -s|>ace, 59

Glandular layer of uterine decidua, 143
Glottis, edema of, in pregnancy, 239
Glycosuria in pregnancy, 232
Goiter in pregnancy, 237
Gonococcus-infection in pregnancy, 217

in puerperal sepsis, 670, 674
Gonorrhea in puerperal state, 63I
Gonorrheal stomatitis of new-born, 813
(ioodell's rule of pregnancy, 201
Graafian follicles, 55
development of, 59

INDEX.

829

Graafian follicles, rupture of, 60
Graduated bougies, dilatation of cervical

canal by, 749
Graves' disease in pregnancy, 237
Gravid uterus. See Pregnant uterus
Gum of new-born, 814

Habitual death of fetus, 175

diagnosis of cause of, 179
preventive treatment of, 180
Harelip, treatment of, 811
Harris- Dickinson pelvimeter, 410
Harris' method of dilating os uteri, 749
Head, fetal, effects of flat pelvis upon,
426-428
extramedian engagement of, 428
structure of, 356
Hearing, disturbances of, in pregnancy,

234
Heart affections of new-born, 816

changes in, in pregnancy, 186
disease in labor, 583
in pregnancy, 236
failure, death from, in labor, 571
muscle, diseases of, in pregnancy, 237
of new-born infant, 792
sounds, fetal, in pregnancy, ausculta-
tion of, 203
Hegar's bougies or dilators, 749

sign of pregnancy, 20I
Hematocele, ante-uterine, 273
from tubal pregnancy, 273
retro-uterine, 274
Hematoma from ruptured tubal preg-
nancy, 273
of vagina, obstruction of labor by, 488
polypoid, of uterus, 146
puerperal, 601

clinical history of, 603
diagnosis of, 603
etiology of, 602
prognosis of, 605
situation of, 601
size and form of, 602
treatment of, 606
rupture of, causing death in labor, 571
Hematuria in pregnancy, 232

in puerperal state, 636
Hemophilia of new-born, 815
Hemoptysis in pregnancy, 240
Hemorrhage, accidental, 534
complicating labor, 525
from laceration of cervix, 552
from umbilicus, 818
castro-intestinal, in new-bom, 818
in placenta pnevia, 529
in third stage of labor, prevention of, 31 2
placental, 127
postpartum, 537

abdominal binder in, 539
auto- infusion in, 542

Hemorrhage, postpartum, causes of, 537
compression of uterus in, 540
diagnosis of, 538
electricity in, 540
ergot in, 539
intravenous injection of salt solution

in, 542
Monsel's solution in, 540
morphin in, 542
rectal injection of salt solution in,

541
symptoms of, 538
tampon in, 540
transfusion of blood in, 542
treatment of, 538
vinegar in, 539
puerperal, 590

from carcinoma of uterus, 600
from dislodgements of thrombi, 598
from displacements of uterus, 595
from emotional causes, 599
from fibroids, 599
from hematomata, 601
from pelvic engorgement, 600
from relaxation of uterus, 599
from retained placenta and mem-
branes, 590
from retention of blood-clots, 599
from wounds of genital tract, 600
unavoidable, 525
Hemorrhagic decidual endometritis, 149
Hemorrhoids in pregnancy, 226

vesical, in pregnancy, 231
Hemothorax of child from injury in

labor, 805
Hernia of pregnant uterus, obstruction
of labor by, 492, 493
umbilical, 137

of new-born, 811
vaginal, obstruction of labor by, 503
Hernial protrusion of pregnant uterus, 21 5
Herpes gestationis in pregnancy, 241
Hick's cephalotribc, 770
Hirst's cranioclast, 769
forceps, 728
knife for cutting subpubic ligament,

776

pelvimeter, 418
Hodge's forceps, 727

scissors, 768
Holoblastic ovum, 60
Hook, blunt, 748

Braun's, 774

Ramsbotham*s, 774
Human milk as food, 795

compared with cows* milk, 797
constitution of, 795
Hydalidiform mole, 105
Hydramnion, 96
Hydramnios, 96

acute, 96

differentiation of, from ascites, 100

830

INDEX.

Hydramnios, differentiation of, from
ovarian cyst, loo
from twin pregnancy, loo
etiology of, 96
from both fetal and maternal sources,

99
from excessive excretion of fetal urine,

from fetal skin, 98

from the amnion itself, 98

of fetal origin, 97

of maternal origin, 96

symptoms and diagnosis of, 99

treatment of, 100
Hydrencephalocele, 510

obstruction of labor by, 512
Hydrocephalus, 513

diagnosis of, 513

treatment of, 514
Hydronephrosis in pregnancy, 230
Hydrorrhea gravidarum, 283
Hydrostatic dilatation of cervical canal,

748
Hymen, 45
unruptured, obstruction of labor by,

489
Hyperemesis gravidarum. See Vomit-

ingy pernicious
Hyperlactation, 649
Hypodermatoclysis in puerperal sepsis,

685
Hysterectomy for puerperal sepsis, 690
Hysteria in pregnancy, 234
Hysterical convulsions, abortion in, 246

Icterus gravidarum, influence of, upon
fetus, 170
of new-born, 816
Iliopsoas muscle, 25
Imjjerforate rectum of child, 812
Impetigo herpetiformis, 241
Impregnation, changes in ovum follow-
ing, 72
time when most likely to occur, 69
Incarceration of pregnant uterus, 21 1

treatment of, 213
Incontinence of urine in pregnancy, 231
Incubation, 792
Incubator, Auvard, 793
Indigestion in pregnancy, 225
Induclion of abortion, 719. See Abor-
tion
Incriia uteri, 401

dia^jnosis of, 403
etiology of, 401
treatment of, 404
Infant, new-born. See N^eiv-born infant
Infundibulopelvic ligament, 55
Inguinal colotomy for atresia ani of new-
born, 812
Injuries of child-birth, repair of, 589

Injuries to infant during labor, 799
Inlet of pelvis, 17
Insanity in pregnancy, 234
Insemination, 64
Insertio velamentosa, 137
Insolation in puerperal state, 613
Insufflation in asphyxia neonatorum, 807
Internal cell -membrane of ovum, 60
Interstitial invagination in fetus, 166
placentitis, 121
pregnancy, 259

abdominal section for, 281

clinical history of, 264

symptoms of, 277

terminations of, 271
Intraperitoneal abscess, abdominal sec-
tion for, 688
Intrauterine amputations, 166
Intussusception of new-bom, 814
Inversion of uterus in labor, 563. See

Uterus^ inversion of
Involution of uterus, 320, 331, 340

abnormalities of, 584

adnexa in, 325

changes in blood-vessels in, 323
in muscle-fibers in, 321-323

endometrium in, 324

ergot for. 340
Irritable uterus as a cause of abortion,

243
Ischiopagus parasiticus, 507

Ischiopubiotomy in obliquely contracted

pelvis, 438

Ischiorectal abscess, 714

Janiceps, 508

Jaundice in pregnancy, 226

of new-born, 816
Jorisenne's sign of pregnancy, 187
Justomajor pelvis, 439
Justominor pelvis, 429. See Pelvis
Juvenile pelvis, 429

Karyokinesis in ovum, 60
Kidney, dislocation of, in pregnancy, 230
of pregnancy, 226

differential diagnosis from nephritis,

228
etiology of, 227
frequency and course of, 227
pathology of, 227
symptoms of, 227
treatment of, 227
Kidneys, diseases of, m pregnancy, 226

in puerperal state, 637
Klebs-Loflfler bacillus in puerperal sepsis,

670
Knots of umbilical cord, false, 133, 136
true, 136

INDEX.

831

Kyesteinic pellicle, 187
Kyphoscoliosis, pelvis of, 473
Kyphosis, 465

Kyphotic pelvis, 465. See Pelvis y ky-
photic

Labia majora, 44

minora, 44

puncture of, for edema of vulva, 219
Labor, 285

abdominal palpation in, 350

action and appearance of woman in,
291

anesthetics in, 303

armamentarium for, 299

bed in, 302

caput succedaneum in, 800

causes of, 286-288

chloroform in, 304

circular detachment of cervix uteri in,

553
clinical phenomena of, 291

complicated by accidents and diseases,

525
by heart disease, 583

by hemorrhage, 525

by pneumonia, 582

by tjrphoid fever, 582
contraction of uterus after, method of

securing, 312
contractions of uterine muscle in, 291
decapitation of fetus during, 803
definition of, 286
descent of uterus in, 288, 289
diagnosis of, 288

diastasis of abdominal muscles in, 570
distortion of head during, 800

<iry, 523
duration of, 290

eclampsia during, 581

embolism of pulmonary artery in, 571

ether in, 304

examination of patient in, 300

expulsive forces of, excessive power

of, 406

first stage of, 293

anesthetics in, 303

management of, 301

pain in, 302

forces involved in, 354

of, anomalies of, 401
fracture of coccyx in, 569

of limbs of child during, 804

of pelvic bones in, 569

of skull during, 800
heart failure in, 571
induction of, in placenta praevia, 532
injuries of, repair of, 589

to bowel of child during, 805

to brain during, 799

to cervix uteri in, 552

Labor, injuries to face during, 803

to infant during, 799

to neck of fetus during, 803

to peripheral nerves during, 799

to scalp during, 800

to trunk of child during, 804
inversion of uterus in, 563
labia in, 294

lacerations of perineum in, 306
treatment of, 558

of vagina in, 554

of vestibule in, 555

of vulva in, 555
liquor amnii in, 305
management of, 298

of,- when obstructed by contracted
pelvis, 480
manner in which uterine muscle acts

on fetal body, 355
mechanism of, 350

abnormalities in, 364

expulsion of trunk in, 364

forces involved in, 354

in breech presentation. 381

In brow presentation, 378

in face presentations, 372

in flat pelvis, 424

in funnel-shaped pelvis, 433

in justominor pelvis, 431

in kyphotic pelvis, 468

in obliquely contracted pelvis, 436

in occipitoposterior positions, 366

In osteomalacic pelvis, 453

in rachitic pelvis, 447

in right occipitO'anteriorposition,366

in shoulder presentation, 393

in third stage, 395

abnormalities of, 396

in vertex presentation, 357

normal, 358

accommodation of fetal head in,

3S8

anterior rotation of occiput in, 361

descent of head in, 360

dilatation of lower segment and of

cervical canal in, 360

external rotation in, 364

propulsion and extension of head

in, 361

restitution in, 361
when occiput rotates into hollow of

sacrum, 367
missed, 188
obstruction of, by abnormal condition

about rectum, 505
by abnormalities of fetal membranes,

523
by abscess of Bartholin's gland, 490

by anus vestibularis or vaginalis, 489

by atresia of cervix uteri, 485

of vagina, 489

by calculi in bladder, 505

832

INDEX.

Labor, obstruction of, by carcinoma of

cervix uteri, 498
by cicatrices of vagina, 488
by cicatricial contraction of cervix

uteri, 486
by closure of vagina, 487
by congenital anomalies of uterus,

484

narrowness of vagina, 491
by cystocele, 505
by displacement of the cervix uteri,

498
by double uterus, 4S4
by edema of vulva, 490
by enlai^ed carunculx myrtiformes,

491
by former fixation of uterus, 493
by gangrene of vulva, 491
by hematomata of vagina, 488
by hernia of pregnant uterus, 492,

493
by hydrencephalocele, 512

by hydrocephalus, 513

by large fetal head, 509

by malformations of fetus, 509

by ovarian cy>ts, 502

by overgrowth of fetus, 505

by placenta pnevia, 525. See Pla-
centa prtTi'ia

by premature ossification of cra-
nium, 509

by prolapse of uterus, 495

by rectocele, 505

by rigidity of cervix uteri, 486

by sacculation of uterus, 495

by septa of vagina, 488

by tumors of fetus, 512
of vagina and vulva, 489

by twins, 518

by unruptured hymen, 4S9

by uterine displacements, 49I
tibroid, 498
polypi, 501

by vaginal enterocele, 503

by vaginismus, 491

by varicose veins, 49I

by Wormian bones, 509
pains of, 280
pathology of, 401
preliminary preparation > for, 298
premature, care of child after, 792

induction of, 721

in overgrowth of fetus, $06
preparations for, 298-300
prevention of hemorrhage in third

stn^e of, 312
profound emotion in, 572
pulse in, 32()

resistant forces of, excess of, 407
rupture of hematoma in, 571

of respiratory tract in. 5 70

of sacro iliac joints in, 569

Labor, rupture of symphysis pubis in,
569
of uterus in, 543. See Uterus^ rup-
ture of
second stage of, 293

clinical features of, 306
shock in, 571, 582
signs of, 288
sloughs of scalp from injury during,

803
stage of descent in, 293
of dilatation in, 293
of expulsion in, 293
stages of, 293

subcutaneous emphysema in, 570
sudden death during, 571
syncope in, 571
temperature in, 298
third stage of, 293, 314
mechanism of, 395
twin, 518

coiling of cords in, 520
mechanism of, 520
placenta in, 521
presentations in, 518
prognosis of, 522
uterine contractions in, 291
vulva in, 294
Laceration of perineum in labor, 306

preventive treatment of, 308
Lactalbumin of human milk, 796
Lactose, 796
I^nghans' cells, II4
Lanugo, 80

Laparo-elytrotomy, 780
Larynx, diseases of the, in pregnancv,

238
Late ligation of cord, 317
Lateral displacement of pregnant uterus,

214
Laleroflexion of the pregnant uterus,

214
Lateroix>sition of the pregnant uterus,

214
Lateroversion of the pregnant uterus,

214
Length of mature fetus, 86
Leukemia in pregnancy, 238
Leukorrhea in pregnancy, 193

vaginal, in pregnancy, 216
Levator ani, importance of, 26
Levrel's forceps, 726
Ligamentous structure of pelvis, 27
Limbs of fetus, fracture of, during labor,

804
Linea nigra, 199
Lipuria in pregnancy, 231
Liquor amnii, 93

abnormalities of. loi

complicating labor, 523

secretion of, 95
composition of, 94

INDEX.

833

Liquor amnii, deficiency of, 95
escape of, in labor, 305
excessive quantity of, 96
origin of, 94
putrefaction of, loi
foUiculi, 59
Lithopedion, 175

Liver, degeneration of, in pregnancy, 226
L. O. A , 353

explanation of frequency of, 353
Lochia, 326
alba, 326
rubra, 326
serosa, 326
Lohlein's method of measuring trans-
verse diameter of pelvic inlet, 420
Longings in pregnancy, 187
L. O. P., 353.
Lordosis, pelvis of, 473
Ldwenhardt's method of estimating dura-
tion of pregnancy, 205
Lungs in puerperal state, 332

of new-born infant, diseases of, 808
septic infection of, 809
Luxation of femora, effect of, on i>elvis,

477
Luxations of fetus, 1 66

Lymphangioma of fetus, obstruction of

labor by, 512

Lymphatic ducts of pelvic organs, 32

Lymphatics of uterus in pregnancy, 182

Malaria in puerperal state, 626

of fetus, 160

relation of, to puerperal sepsis, 717
Male pronucleus, 69
Mammae, absence of, 641

congestion and engorgement of, 654

hypertrophy of, 641

supernumerary, 641
Mammary abscess, 657
in pregnancy, 221

binder, 346

changes in puerperal state, 333

glands, diseases of, 652

management of, in puerperal state,

344
structure of, 333

tumors, 658

in pregnancy, 221
Manual method of dilating os uteri, 749

of extracting breech, 745
Marginal insertion of cord, 136
Marshall Hall's method of artificial respi-
ration, 807
Martin's pelvimeter, 410
Masculine pelvis, 429
Mastitis, 656

of new-bom, 811
Maternal blood, alterations in, that are
fatal to fetus, 176

Maternal emotions, influence of, upon
fetus, 169
fever, influence of, upon fetus, 168
Maturation of ovum, 60
Mature fetus, 85

appearance of, 87
dimensions of head of, 86
length of, 86
weight of, 85
Mauriceau's method of delivering after-
coming head, 763
Measles in fetus, 158
in pregnancy, 240
in puerperal state, 623
Mechanism of labor, 350. See also
Labor y mechanism of
forces involved in, 354
normal, 358
of various positions, 357
presentations, 357
Melancholia in pregnancy, 187
Melena of new-born, 818
Membrana decidua vera, 139
granulosa of Graafian follicle, 59
reflexa, 139
serotina, 139
Membranes, fetal, abnormalities of, com-
plication of labor by, 523
retention of, puerperal hemorrhage
from, 590
Menstrual flow, character of, 58
duration of, 58
quantity of, 58
molimina, 58
Menstruation, 56
and ovulation, connection between, 63
cessation of, 59

as a sign of pregnancy, 191
in extra-uterine pregnancy, 275
time of onset of, 57
Mesoderm, 72
Mesonephros, 42

Metritis, chronic, as a cause of abortion,
176
dissecting, in puerperal sepsis, 697
in pregnancy, 215

treatment of, 215
septic, in puerperal fever, 697
Micro-organisms, behavior of, in genital
canal, 673
capable of producing puerperal sepsis,

670
manner of entrance of, into genital

canal, 671
passage of, from mother to fetus, 156,

.. '57
Miliary tuberculosis in pregnancy, 239

Milk, colostrum-corpuscles in, 652

cows', constitution of, 797

effect of emotions on, 647, 651

human, as food, 795

constitution of, 795

Milk. quiSiutiTe tnomiliu in. 651

■44

raiment at. 048

Xecrceis of pclvii, 459
NcphriliB, diflerenlial diignoiia of. 11
kidney of pregnancy, iti
in pregnnncy, 217

treaiment of. 2;S
maternal, elleci uf. upon Ittin. 177
Nerves of generaiive orgin?, 5:
of ulerus. changei in, id gircgoai

Mi^-jzr.tit. i+j. 25S. See also .^,V#•-

1S2

rvouj system, changes in. in ff»j-

M-.iHsi .Iv-ioii. 35S

nancy. ISj

Ijtvr. 1>>

diseases of. in pregnancv. 131

N"e

Mv:«. iiiUL. J!r"

Neuritis in puerperal Male. 640

SL>'.:aiai. mensiiui;. 5S

M«i V.«rii. 4,5

w-bom infant. 7S9

t-?-'

airing of. 799
Bphth.v of, S13

jrvtmaence of. in prrsnincv. 194

artitidal feeding of, 796

Motr.-.=i«c..::e»..lS:

respiration of. S07

Mor.::!. :--

asptivsiaof. 8=6

Mcoe:. cb-iJox- disei*i of, efleci of,

ate1ecla±,is of, SoS

B:«ifr;=s. i:r

Btreiiaani in, Sij

cmkiidoiH of. which injuriouilv siTeel

bathing of. 79S

•e;-^.. I'-vS

blood in, 791

diilh >.•:. ff:TVti ■.■f. upon felu.-. 171

bloody di«hai^e from kr^e

d:r:<.t:--i* for. j;47

;;enilalia of. Slcl

ertrvt -.1 d*i:n of feiu' upon, 17:

cagiacilv of stomach of, 790

M.'czh-Evi Bi'.>u:h iiuunUiioo in a^fdiriia

care ofi 316, 346

:;*» a4:..TJin. S07

direction* to nune for. J4S

M5.vti>:;jj. 1S6

cephalhematoma of. Soi

M-.-.etr; m»,. ri

cleflpalaleof. Sli

M-:enani-..T*.,!*40

clolhing ff. 705

Slirv.;; r.b>. IIS S« Za.v-r. /ain

colic of. Sll

T<:i:-,'=. So See f^.-j.':.«

conjunctivi,isof,St5

lao:*. TS. d;:jtai!OTi of at uleri by, 749

consii,K.tionin.Si3

::?;;■»:■.;» -^s .-.■.■.■ «. "ta.'.-i.-.V

cyanr^is of. Sib

Mj-,=i .-TSA-t -indfr. 140

Mi>::*-7i*r» of uKnii, aheialioni in.

digestit^ in. 7<jo

:: t re^cja.T. iSi

di^^as^s of. SoS

Mils.;!;: of pelris, ^5

lung> of. SoS

Mji*.:::*, ii^-esdi-;.' ir, i-ueireral Hate.

evanlhemsta of. Sll
eyesight in, 701

Mi.v.;-:-.;:^. br(-«s itr^iphj of, in prcg-

fcedinR of, 795
furuncles in, S14

Mvr-.e;r.un..'Vv:;un.J!i*>a of. in v"S

ga^lrO' intestinal hemorrbagt in,

>!vi,-. ■.:,.;;!!■ ;:40(nt*. IIJ

general appearance of. 87

.•: :>:;?. :':r:ri;::.'i: ■>( UU-c in. ^l^

M.v.rM^-.:. :.;rT:-rAi!.n of pli,™!..

harelip of. Sll
heart of, 7.JJ
affections of, S16

Nir^e'e'* ::;.: : .f e-rimjling duration

icierusof. 1{|6

inflammation of umbilical reueb

pt.\ 1. 4.;4. -« A-": .J, VB/ ■■.I, ■,•<■</,

ID. SiS
injuries to, during labor, 790

Nxtil .iiir-:: .•:' ne* bom. St?

intussusception tn, S14

N*ui;'i lal io'!;;;!r.i; in pregnaooy. 1S7,

jaundice of, S16
manaBemenl of. 795

Nev-k. ;n;I:i;^ ,■;■. J.iHns Ubor. S115

maslilisof, 811

INDEX.

835

New-born infant, medication of, 820
melena of, 818
movements of bowels in, 790
nasal catarrh of, 813
omphalitis in, 817
ophthalmia of, 815
pathology of, 790
pemphigus of, 814

syphilitic, 814
physiology of, 789
pneumonia of, 809
position of stomach in, 790
pulmonary apoplexy of, 810
pulse in, 791
respiration of, 789

physiology of, 806
septic infection of lungs of, 809

of umbilicus of, 817
septicemia of, 81 1
skin diseases of, 814
sublingual cysts of, 813
sudden death of, 820
sjrphilis of, 810

of lungs of, 809
temperature of, 790
tetanus of, 818
thrush of, 813
tuberculosis of, 809
umbilical cord in, 792
fungus in, 817
hernia in, 811
urine in, 790
weight of, 789
wet-nurse for, 796
white pneumonia of, 809
Nipples, anomalies of, 643
care of, 189

eczema of, in pregnancy, 221
sore, 655
Nipple-shield, 655

Nose, affections of, in pregnancy, 238
Nurse, directions for, 348
Nymphae, 44

Oblique diameters of pelvis, 22

pelvis, 434. See Pelvis ^ contracted j
obliquely
Obstetric examination in labor, 300
Obstetrical binder, 313
Obturator membranes, 27
Occipito-anterior position, 353

mechanism of labor in, 357

right, mechanism of, 366
Occipitoposterior position, 353

diagnosis of, 366

mechanism of labor in, 366

prognosis of, 369

treatment of, 369
Oligohydramnios, 95
Omphalitis of new-born, 817
Omphalorrhagia, 818

Ophthalmia neonatorum, 815

Os uteri, arti6cial dilatation of, 748. See

Cervical canal, dilatation of
Osiander's pelvimeter, 410
Ossification of cranium, premature, ob>

struction of labor by, 509
Osteomalacia of pregnancy, 240
Osteomalacic pelvis, 450
Osteophytes in pregnancy, 187
Ostium abdominale of oviduct, 53

internum of oviduct, 53
Outlet of pelvis, 17
Ovarian arteries, 32
pregnancy, 259

clinical history of, 265
operation for, 281
terminations of, 271
Ovario-abdominal pregnancy, 259
Ovariopelvic ligament, 55
Ovariotomy for ovarian cyst complicating

pregnancy, 502
Ovary, anatomy of, 54

cysts of, complication of labor by, 502
development of, 40
germinal epithelium of, 59
Oviducts, anatomy of, 50
Ovular decidua, 140
Ovulation, 59

and menstruation, connection between,

Ovule and spermatic particle, meeting-
place of, 68
Ovum, changes in, following impregna-
tion, 72
deutoplasm of, 60
discharge of, from ovary, 61
fertilization of, 69
germinal spot of, 60

vesicle of, 60
internal cell -membrane of, 60
maturation of, 60

a cause of labor, 287
migration of, to uterine cavity, 62
polar globules of, 60
premature expulsion of, 243. See

Abortion
protoplasm of, 60
transmigration of, 62
vitelline membrane of, 60
yolk of, 60
zona pellucida of, 60

Pain in extra-uterine pregnancy, 274

Pains in labor, 289, 291

Palfyn's forceps, 725

Palpation, abdominal, in labor, 350

Paralyses, spinal, in pregnancy, 233

Paralysis in puerperal state, 640

Para-uterine phlebitis in puerperal sepsis^

702
Parovarium, 40, 42

836

INDEX.

Parturition, epistaxis in, 238
Pelvic bones, fracture of, in labor, 569
cavity, measurement cf capacity of, 422
direction, 24
engorgement a cause of puerperal

hemorrhage, 600
joints, ankylosis of, 459

changes in, in pregnancy, 186
loosening of and pain in, in preg-
nancy, 220
relaxation of, 459
after lalx>r, 658
suppuration of, 714
lymphatic glands, 32
organs , sensations in , in pregnancy , 1 93
peritonitis in puerperal fever, 699
position, 22
shape, 20
size, 22

tumors, putrefaction of, 713
Pelvimeter, 409, 410
Harris-Dickinson's, 410
Hirst's, 418
Martin's, 410
Osiander's, 410
Pelvimetry, 409

Skutsch's method of, 422
Pelvis, anatomy of, 17

obstetrically considered, 20
anomalies of. See Pelvis^ deformities

of
blood-vessels of organs of, 32

brim of, 17

caries of, 459

cavity of, measurement of capacity of,

422
connective tissue of, 28
contracted, Cesarean section in, 483,
484
forceps in, 482
generally, 429. See Pelvis^ justo-

minor
induction of premature labor in, 480
management of labor in, 480
obliquely, 434

characteristics of, 434
diagnosis of, 436
etiology of, 435
influence of, on labor, 436
prognosis of, 437
treatment of, 437
symphyseotomy in, 483
transversely, 438
version in, 482, 754
coxalgic. 475

(lefornieci, frequency of, 407
deformities of, 407
classification of, 408
<lescription of, 423
diagnosis of, 409
deformity of, from absence of both
lower extremities, 479

Pelvis, deformity of, from absence of one
lower extremity, 479

from clubfoot, 480
development of, 24
diameters of, 22
direction of, 24
dwarf, 429, 430

effect of luxation of femora upon, 477
exostoses of, 453
fetal, 432
flat, non-rachitic, 43 1

rachitic, 441

simple, 423

diagnosis of, 424
etiology of, 424
influence of, upon labor, 424
fracture of, 456
funnel-shaped, 432
inclination of, 22
inferior strait of, 17
inlet of, 17, 18
justomajor, 439
justominor, 429

characteristics of, 429

etiology of, 430

influence of, on labor, 431
juvenile, 429
kyphoscoliotic, 473
kyphotic, 465

characteristics of, 466

diagnosis of, 471

frequency of, 472

influence of, on labor, 468

prognosis of, 472

treatment of, 470
ligamentous structures of, 27
lordosic, 473

lymphatic ducts of organs of, 32
masculine, 429
muscles of, 25
Naegele's, 434. See Pelvis^ contracted

obliijuely
nana, 429

nerves of organs of, 32
obliquely contracted, 434
obtecta, 468
osteomalacic, 450

diagnosis of, 452

influence of, upon labor, 453

treatment of, 453
outlet of, 17
plana, 423
position of, 22
pseudo-osteomalacic, 444
rachitic, 440

characteristics of, 440

diagnosis of, 445

Hat, 441

influence of, on labor, 447
Robert's, 438. See Pelvis, contracted^

fr(ins7>erseiy
scoliotic, 472

INDEX.

837

Pelvis, shape of, 20
simple flat, 423
sitz, 479
size of, 22
soft tissues of, 25
spinosa, 453
split, 439

spondylolistbesic, 460
characteristics of, 460
diagnosis of, 462
etiology of, 462
influence of, upon labor, 464
treatment of, 465
superior strait of, 17
true, 17
tumors of, 453
undeveloped, 432
Pemphigus of new-born, 814

syphilitic, 814
Pendulous belly, obstruction of labor by,

492
Peptonuria from death of fetus, 1 74
in pregnancy, 231
in puerperal state, 635
Perforator, Blot's, 768, 769

Smellie's, 768, 769
Perineum, laceration of, in labor, 306
treatment of, 558
supporting of, 308-310
Periodicity a cause of labor, 287
Peripheral nerves, injury to, during labor,

799
Peritoneal covering of uterus, changes of,

in pregnancy, 181
Peritonitis, diffuse, in puerperal sepsis,
699
suppurative, abdominal section for,
688
lymphatica in puerperal sepsis, 700
pelvic, in puerperal fever, 699
Peri -uterine adhesions in pregnancy, 220

inflammations in pregnancy, 220
Pernicious anemia in pregnancy, 238

vomiting, 222. See Vomiting
Pfluger's theory of menstruation, 56
Phlebitis, para-uterine, in puerperal sep-
sis, 702
uterine, in puerperal sepsis, 702
Phlegmasia alba dolens in puerperal sep-
sis, 706
Phthisis in puerperal state, 615
placental, 123

pulmonalis in pregnancy, 239
Physical disturbances in pregnancy, 234
Pigmentation, exaggerated, in pregnancy,
242
of areolae, exaggerated, 654
Placenta, 112
adhesion of, 397
diagnosis of, 398
prognosis of, 399
treatment of, 398

Placenta, anatomy of, 117
annular, 120
anomalies of, 119

of number of, 1 19

of position of, II9

of shape of, 1 19

of size of, 119

of weight of, 119
calcareous degeneration of, 124
circular vein of, 118
cotyledons of, 118
cysts of, 129
delivery of, 314

in twin labor, 521
detachment of, premature, 534
causes of, 535
diagnosis of, 535
prognosis of, 536
symptoms of, 535
treatment of, 536
development of, 112
duplex, 120
edema of, 120

expression of. Credo's method of, 396
expulsion of, mechanism of, 395
fatty degeneration of, 1 21
fibrofatty degeneration of, 1 21
fibrous degeneration of, 1 21
functions of, 1 18
hemorrhages of, 127
hernia of, through muscular coat of

uterus, 390
manner of separation of, 297 •
membranacea, 104, 119
multiloba, 120

myxomatous degeneration of, 123
previa, 525

abortion in, 530

clinical history of, 528

diagnosis of, 530

etiology of, 527

frequency of, 525

hemorrhage in, 529

history of, 525

induction of labor in, 532

prognosis of, 534

symptoms of, 530

tampon in, 533

varieties of, 527
retained, a cause of puerperal hemor-
rhage, 590
retention of, 396, 524

in double uterus, 485
syphilis of, 124
tripartita, 120
tumors of, 129
villi of, 112

cellular hypertrophy of, 12 1
Placentae succenturiata?, 120
Placental decidua, 140
hemorrhages, 127
phthisis, 123

838 IN

Flacenul polypus, 146

Tjlli, celluiar hTpertrophj of, 121
Placenlilis. liE

interslitial, 121
Pl*nt^ of |ielvic contraction, 31

enpansioti. 21
Plethora, nurmial. eflect of, on fetus.

Pleurisy in prrgnancj. 140

PneamociKcus in puerperal sepsis. 670
PneuiDoiiia. com plication of labor by,

in pregnuncy. 259

in puerperal slate. 616

of neir-|ii>m infant, S09
Podaliceision, 757
Puiwning, chninic.eflectof, apoD mother,

Polar bo.'lIfi or globules, 60

Polygalaclia. 649

Poll hvilramn ion. 96

Pulymailla. 641

Polvpi. uterine, obiitruclion uf labor bj,

501
Poly,W eudanierr-iis, 146

citisiD,226
areola in, 194
asthma in, 239
au scu I tat ury sounds of, jo:
blindness in, 234
blood in, 1S6
breasts in, 193, 194
broad ligament in, 261
broncliial calartli in, 239
cariesof teeth in. 221
cervical, of Rokitansky, IJO

Polv.

I'olyu

.*.pUce

. 140

n pregnancy. 231

n abdominal nail
n bladder in. 1S6
n lilood in. 1S6

in respiTatory apparatu.- in,
in sevtM^l l«^i|y sysiemsin
in urine in. 1S7

chloasmata of. 194

oecipiio-anterior. 353

chyluHain, 231

*e,[.ii..[>.*ieT,or. 353. See A

ifilo-

colpohyperpla.'iia cystica in. ;i

combined, examination in, loi

of iVius. diagnojis of, bv aWominal

coiigestiou of brain in. 232

,aljMiK.n.3SI

con-iipation in. It>7, iSS

ireatmcnl of, 225

Posiri.iii;. meibaixijin ol. 357

cystitis in. 23,

]'o^ira,innuarv alwcess. 05:

degeneration of liier in. 2;6

Posrmonem Cesarean section, 779

diabetes mellitns in, 232

.^•l^very. 573

diagnosis of, 1S9-210

P,.-!p.i,iml.emorrl.aEe,S37. Sec//™- 1

diarrhea in, treatment of. 22t

diet in. 1S9

Pi'stural version. 750

diminution of urine in. 231
diseases of alitnenlar) canal io

Picture. Walcher. 4SJ. 4S4

P.itf* dinMse in pregnancy. 140

of t>lood in. x^S

PiMiirt's ,i\istr.Actioii forcpp^, 730

<•( blood Tcs&els in, 237
of brain in, 232

l'rii:uf mi-di.i.l of delivering afler-cc

ming

of respiratory a^iparatis in, 23S
of s|>inal cord in, a^j
of vagina in, 3l6

of kidney in. 230
S of ulcru» in. 210
of hearing of, 234,

INDEX.

839

Pregnancy, disturbances of vision in, 234

dullness on percussion in, 203

duration of, estimation of, 204

ectopic, 259. See Pregnancy^ extra-
uterine

eczema of nipples in, 221

edema of vulva in, 218

emphysema in, 239

endocerviciiis in, 216

epilepsy in, 233

epistaxis in, 238

exaggerated pigmentation in, 242

extra-uterine, 259

face of woman in, 194

fetal heart-sounds in, 203
movements in, 193
palpation of, 201

fibromata of uterus in, 21 5

funic souffle in, 203

general changes in, 186

gingivitis in, 221

glycosuria in, 232

goiter in, 237

Graves' disease in, 237

heart disease in, 236

hematuria in, 232

hemoptysis in, 240

hemorrhoids in, 226

hernial protrusion of uterus in, 215

hydronephrosis in, 230

hysteria in, 234

incarceration of uterus in, 21 1

incontinence of urine in, 231

indigestion in, 225

infection with gonococcus in, 217

in horn of uterus bicomis or unicornis,
282

injuries of, 242

insanity in, 234

interstitial, 259. See Interstitial preg-
nancy

jaundice in, 226

kidney of, 226

kyesteinic pellicle in, 187

lateral displacements of uterus in, 214

lateroHexion of uterus in, 214 *''

lateroposition of uterus in, 214

lateroversion of uterus in, 214

leukemia in, 238

leukorrhea in, 193

linea nigra in, 199

lipuria in, 231

longings in, 187

loosening of and pain in pelvic joints
in, 220
of finger-nails in, 242

mammary abscess in, 221
tumors in, 227

management of, 188

measles in. 240

melancholia in, 187

metritis in, 215

Pregnancy, miliary tuberculosis in, 239
morning sickness in, 187
multiple. See Fetation^ multiple
nausea and vomiting in, 187, 192
nephritis in, 227
nervous system in, 187
neuralgias in, 187, 233
neuroses of, 233
osteomalacia of, 240
osteophytes in, 1 87

ovarian, 259. See Ovarian preg-
nancy
ovario-abdominal, 259
palpation of abdomen in, 200
peptonuria in, 231
peri -uterine adhesions in, 220

inflammations in, 220
pernicious anemia in, 238

vomiting in, 222
phthisis pulmonalis in, 239
physiology of, 1 81
pleurisy in, 240
pneumonia in, 239

polypoid hypertrophies of vaginal mu-
cous membrane in, 217
polyuria in, 231
Pott's disease in, 240
prior, diagnosis of, 208
prolapse of uterus in, 214
prolongation of, 188
pruritus in, 241

vulvae in, 218, 241
ptyalism in, 192, 222
pulmonary emlx>Iisio in, 239

tuberculosis in, 239
purpura hsemorrhagica in, 238
pyelitis in, 230
quickening in, 193
renal calculus in, 230

tumors in, 230
respiratory apparatus in, 188
retroflexion of uterus in, 211. See Re*

troversion
retroversion of uterus in, 211
salivation in, 192
signs of, 191

objective, 193

on auscultation, 202

on inspection, 194

on sense of touch, 200

subjective, I9I
skin diseases in, 241
spurious, 209
strice, mammary, in, 104
suburethral abscess in, 217
surgical operations in, 242
syphilis in, 240
tetany in, 234
toothache in, 221
torsion of uterus in, 215
tubal. See Tubal pregnancy
tubo-abdominal, 259, 273

^43

IVspiirr' r-zS>-o»«!;»n. 250.

ilion, compound. 516
ircBlnieiit of, 517
denDilion of, 350
diagDosis of, b; abdominal pil^

■s of, 3

i in mtcliinisni of. ;"l

diaguusis of, 370
frequency of, 370
mechanism of. 371
prognosis of, 374
treatment of, 374
mechiinUm of. J57
of greater fontanel. 379
shoulder, jSS
cauf(r« of. 303
diagno&izi of. 3^^

-a=x 1= j-rtp-.*=cT, 1

INDEX,

841

Puerperal sepsis, care of patient in, 677
clinical history of, 696
diagnosis of, 674
diffuse peritonitis in, 699
dissecting metritis in, 697
encolpitis in, 696
endometritis in , 696
etiology of, 662
exploratory abdominal section in,

694
forms of, 696
hypodermatoclysis in, 684
hysterectomy for, 690
microbes of, manner in which they

Bnd entrance, 67 1

that produce, 670
milk-leg in, 706
morbid anatomy of, 696
operative treatment of, 685
pelvic peritonitis in, 699
phlegmasia alba dolens in, 706
precautions in regard to implements,

679

on part of nurse in, 679
physician in, 679
preventive treatment of, 675

physician in, 678
proctitis, 713
putrefaction of pelvic and abdominal

tumors in, 713
pyelitis in, 712
relation of diphtheria to, 716

of erysipelas to, 716

of infectious fevers to, 715

of scarlet fever to, 717
salpingitis in, 696
salpingo-odphorectomy for, 689
sapremia in. 709
septic cystitis in, 712

metritis in, 697
septicemia in, 709
serum- therapy of, 68 1
symptoms of, 674
tetanus in, 713
treatment of, 679

by artificial hyperleukocytosis,
684

by washing the blood, 684

preventive, 675
ureteritis in, 712
uterine phlebitis in, 702
water in, 676
state, 319

acute intercurrent affections of, 615

after-pains in, 328

alterations in circulatory apparatus

in, 329
anemia in, 588
a|X)plexies in, 640
appetite in, 332
arthritis in, 296
ascending myelitis in, 640

Puerperal state, bowels in, 342
breasts, care of, in, 344
care of child in, 346
catheter in, 342

change in urinary system in, 330
cystitis in, 638
diagnosis of, 336
diastasis of abdominal muscles in,

632
diet in, 340
diphtheria in, 626
directions to nurse for, 349
edema of genitals in, 590
erysipelas in, 623
erythematous rashes in, 622
fever in, emotional, 607

from cerebral disease, 612

from constipation, 610

from exposure to cold, 609

from reflex irritation, 610

non-infectious, 607

syphilitic, 614

with eclampsia, 613
fibroids in, 599
gonorrhea in, 631

hematoma in, 601 . See Hematoma
hematuria in, 636
incontinence of urine in, 637
insolation in, 613
involution of uterus in, 320
kidneys in, 637
lesions of sacral plexus in, 640
lochia in, 326
malaria in, 626
mammary abscess in, 657

changes in, 333

glands in, care of, 344
management of, 337
mastitis in, 656
measles in, 623
neuritis in, 640
nursing in, 349
paralysis in, 640
pathology of, 584
peptonuria in, 635
phthisis in, 615
physician's visits during, 337
pleurisy in, 617
pneumonia in, 616
pulse in, 329
pyelonephritis in, 639
rest and quiet in, 338
rheumatism in, 629

muscular, 631
scarlet fever in, 617
secretion of milk in, 644
skin diseases in, 632
small-pox in, 623
sun-stroke in, 613
sweat-glands in, 332
temperature in, ^tZZ
thirst in, 332

842

INDEX.

Puerperal state, tympanites in, 632
urination in, 342
urine in, 634
visits of friends in, 339
weight, loss of, in, -t^it,
Puerperium. See Ptierperal staU
Pulmonary apoplexy of new-bom, 810

embolism in pregnancy, 239
Pulse during labor, 329
in new-bom infant, 791
in puerperal state, 329
Puncture of labia for edema of vulva, 219
Purpura hoemorrhagica in pregnancy, 238
Putrefaction of pelvic and abdominal

tumors, 713
Putrid absorption in puerperal sepsis, 709
Pyelitis in pregnancy, 230
in puerperal sepsis, 712
Pyelonephritis in puerperal state, 639
Pyopagus, birth of, 51 1

Quickening, So, 193

value of, in estimating duration of
pregnancy, 205

Rachitic pelvis, 440. See Pehis^ ra-
chitic
Rachitis of fetus, 163
Ramsbotham hook, 774
Rectocele, obstruction of labor by, 505
Rectum, abnormal conditions of, obstrac-
tion of lalx)r by, 505
changes in, in pregnancy, 186
imperforate, of child, treatment of, 812
Recurrent fever of fetus, 162
Relaxation of pelvic joints, 460
Renal calculus in pregnancy, 230

tumors in pregnancy, 230
Resistance, forces of, 354
Resistant forces of labor, excess in, 407
Respiration of new-bom infant, 789

physiology of, 806
Respiratory apparatus, changes in, in
pregnancy, 188
diseases of, in pregnancy, 238
tract, rupture of, in labor, 570
Restitution, anomalies of, 365
in face presentation, 372
in vertex presentation, 361
Retention of placenta, 396

of urine In puerperal state. 342
Retroflexion of pregnant uterus, progno-
sis of, 212

symptoms of, 211
terminations of, 212
treatment of, 21 2
when uterus is incarcerated,

Retro-uterine hematocele, 274
Retroversion of pregnant uterus, 211

Rheumatism, articular, of fetus, 162
in puerperal state, 629
muscular, in puerperal state, 631
of myometriimi in pregnancy, 215
Ring of Band!, 183, 354, 544
R. O. A., 353
Robert pelvis, 438. See Pelvis^ con-

tracted^ transversely
Rosenmiiller, body of, 42
Rotation, extemal, anomalies of, 365
in face presentation, 372
of fetal head, 364
of fetal head, 361

anomalies of, 365
of occiput in face presentation, 372
in occipitoposterior position, 366
abnormalities of, 367
Rupture of membranes, artificial, 305
of umbilical cord, 575
of uterus, 543. See Uterus^ rupture of

Sacculation of uterus, 212
obstmction of labor by, 495

Sacral plexus, lesions of, in puerperal
state, 640

Sacrococcygeal joint, ankylosis of, 459
fracture of, in labor, 569

Sacro-iliac joint, mpture of, in labor, 569
synostosis of, 459

Sacrosciatic ligaments, 27

Sacrum, fracture of, 457

Saddle-shaped back, 462

Salivation in pregnancy, 192

Salpingitis in puerperal fever, 696

Salpingo-oophorectomy for puerperal sep-
sis, 689

Sanger method of Cesarean section, 780,

784
Sapremia in puerperal sepsis, 709
Scalp, injury of, during labor, 800
Scarlatina of fetus, 159
Scarlet fever in puerperal state, 617
frequency of, 618
infection and incubation of, 618
ficculiarities of, 620
prognosis of, 62 1
symptoms and diagnosis of, 619
of fetus, 159

relation of, to puerperal sepsis, 717
Schatz's method of cephalic version, 376
Schnitzels method of artificial respira-
tion. 807
5>clerema of premature infants, 795
Scoliosis, 472

Scoliotic pelvis, 472. See /V/ti>, scoli-
otic
Seminal fluid, description of, 64

mechanism of ejaculation of, 66
of reception of. within genital
canal of female, 67
granule of spermatozoon, 65

INDEX.

843

Septic infection of lungs of new-bom in-
fant, 809
of umbilicus of new-bom, 817
Septicemia in puerperal sepsis, 709
of fetus, 161
of new-bom infant, 811
Serum-therapy in puerperal sepsis, 681
Sex, determination of, 87

of fetus, diagnosis of, 208
Shock, death from, in labor, 57 1

in labor, 582
Shoulder presentation, 388. See Presen-
tation
Shoulders, descent, rotation, and birth

of, 364
Show, 290
Signs of pregnancy, 191

ascertained by auscultation, 202
by inspection, 194
by sense of touch, 200
objective, 193
subjective, 191
Simple flat pelvis, 423
Simpson's cranioclast, 769

forceps, 728
Sitz-pelvis, 479

Skin diseases in pregnancy, 241
in puerperal state, 632
of new-bom, 814
Skull, fracture of, during lalx>r, 800

injury to, during labor. 800
Skutsch*s method of pelvimetry, 421,

422
Sloughs of scalp of infant from injury

during labor, 803
Small-pox in puerperal state, 623
Smellie's forceps, 726
perforator, 768. 769
Snuffles, 813
Somatopleure, 73
Souffle, funic, 203

Spermatic particles in semen, first appear-
ance of, 65
Spermatozoa, 64
meeting-place of, with ovule, 68
power of motion of, 65
time of disappearance of, from semen

of old men, 66
vitality of, 65
Spina bifida, treatment of, 8l2
Spinal cord, inflammation of, in preg-
nancy, 233
paralyses in pregnancy, 233
Splanchnopleure, 73
Split pelvis, 439
Spondylizema, 465
Spondylolisthesis, 460
Spondylolisthetic pelvis, 460. See Pelvis^

spondylolisthetic
Spongy layer of uterine decidua, 143
Spontaneous evolution, 394
version, 394

Spurious pregnancy, 209
Staphylococci in puerperal sepsis, 670
Stein's instmment for measuring conju-
gate, 413
Stethoscope, use of, in diagnosing preg-
nancy, 204
Still-births, repeated, diagnosis of causes

of, 179
Still-bom children, habit of giving birth

to, 179
Stomach, capacity of, in new-bom infant,
790
position of, in new-bom infant, 790
Streptococcus pyogenes in puerperal sep-
sis, 670, 673
Striae, mammary, 1 94
Subinvolution, 585
causes of, 585
diagnosis of, 586
treatment of, 587
Sublingual cysts in new-bom, 813
Suburethral abscess in pregnancy, 217
Sugar of human milk, 796
Sun-stroke in puerperal state, 613
Superinvolulion, 584
Supernumerary digits, treatment of, 81 1
Suppuration of pelvic joints, 714
Supravaginal portion of utems, 47
Surgical operations in pregnancy, 243
**Sway " back, 462
Sweat-glands in puerperal state, 332 .
Symphyseotomy, 774
by French method, 779
by Italian method, 776
indications for, 775
in labor with contracted pelvis, 483
technic of, 776
Symphysis pubis, rupture of, in labor,
569
synostosis of, 459
Syncephalus, craniotomy for, 513
Syncope after labor, 571
Syncytial cancer, 1 29
Syncytium, 112, 114
Synostosis of pelvic joints, 459
Syphilis, fetal, 151
diagnosis of, 1 53
manifestations of, 152
prognosis of. 1 53
treatment of, 155
\Vegner*s sign of, 154
in pregnancy, 240
of lungs of new-bom infant, 809
of new-bom infant, 810
placental, 124
Syphilitic fever in puerperal state, 614

Tarnier's axis-traction forceps, 730

basiotribe, 770, 771

sign of inevitable abortion, 252
Teeth, caries of, in pregnancy, 221

844

INDEX.

Temperature of fetus in utero^ 84

of new-bom infant, 790
Teratoma of fetus, obstruction of labor

by, 511, 512
Tetanus bacillus in puerperal sepsis, 670
in puerperal sepsis, 713
of new-bom, 818
Tetany in pregnancy, 234
Theca folliculi, 59
Third stage of labor, 314

mechanism of, 395
Thirst after delivery, 332
Thoracopagus, birth of, 51 1, 512
Thrombi, displacement of, as a cause of

puerperal hemorrhage, 598
Thrombosis of pulmonary artery m labor,

571

Thrush of the new-born infant, 813

Tongue-tie, treatment of, 81 1
Toothache in pregnancy, 221
Torsion of pregnant uterus, 215
Transmigration of ovum, 62
Transverse diameter of pelvis, 22
measurement of, 420
pelvic outlet, measurement of, 422
presentation, 388. See Presentation
Transversely contracted pelvis, 438. See

PeiinSf contracted
Traumatism, fetal, 167
True conjugate, measurement of, 413, 414

corpus luteum, 63
Trunk of child, injuries of, during labor,

804
Tubal abortion, 272
moles, 271

pregnancy, abdominal section for, 279
atrophy of sac in, 267
clinical history of, 261
pathology of, 261
rupture of sac of, 267
vaginal section for, 281
varieties of, 259
Tuberculosis of fetus, 160
of new-born infant, 809
pulmonary, in pregnancy, 239
Tubo-abdominal pregnancy, 259, 273
Tubo-ovarian ligament, 53
pregnancy, 259

clinical history of, 265
Tubo-ulerine pregnancy, 259

terminations of, 271
Tumors of fetus, obstruction of labor by,
512
of genital canal, obstruction of labor

by, 498
of pelvis, 453
of placenta, 129
of umbilical cord, 138
of vagina and vulva, obstruction of
labor by, 4<S9
Tunica fibrosa of Graafian follicle, 59
media of Bischott, 93

Tunica propria of Graafian follicle, 59
Twin labor, 518. See Labor
Tjrmpanites in puerperal state, 632
Typhoid fever in pregnancy, 240

labor complicated by, 582

of fetus, 161

Umbilical cord, 132
anomalies of, 134
calcareous degeneration of, 1 38
coiling of, around fetus, 136
cysts of, 138
description of, 133
development of, 132
exaggerated twisting of, 134
false knots of, 133, 136
hernia into, 137
in new -bom infant, 792
marginal insertion of, 136
short, complicating labor, $23
true knots of, 135
tumors of, 138
velamentous insertion of, 137
fungus in new-bom, 817
hernia, 137

of new-bom, 811
vesicle, 132
vessels, 133

inflammation of, 818
rupture of, 135
stenosis of, 135
varices of, 1 35
Umbilicus, changes of, in pregnancy, 199
hemorrhage from, 818
inflammation of, 817
of new-bom, septic infection of, 817
Unavoidable hemorrhage, 525
Undeveloped pelvis, 432
Urea, excess of, in maternal blood, effiect

of upon fetus, 177
Ureteritis in puerperal sepsis, 7 1 2
Urinary apparatus, diseases of, in preg-
nancy, 226
system, changes in, in puerperal state,

Urination in puerperal state, 342
Urine, anomalies of, in pregnancy, 231
changes in, in pregnancy, 187
diminution of, in pregnancy, 231
examination of, in pregnancy, 188
excessive secretion of, a cause of hy-

dramnios, 98
incontinence of, in pregnancy, 231

in puerperal state, 637
in new-bom infant, 790
in puerperal state, 634
of mother after death of fetus, 1 74
retention of, after labor, 330
Urogenital sinus, 39, 40, 42
Uterine adnexa, involution of, 325
artery, 32

INDEX.

845

Uterine bruit, 203

contractions in labor, 291
decidua, 140

compact layer of, 140
glandular layer of, 143
spongy layer of, 143
milk, 114

muscle, contraction of, in labor, 291
deficient power of, 401. See also

Inertia uteri
diseases of, 215

in pregnancy, 215
manner in which, acts on fetal body,

355
phlebitis in puerperal sepsis, 702

segment, lower, 354

upper, 354
Utero-abdominal pregnancy, 260

clinical history of, 265
Utero-ovarian ligament, 55
Uterus, alterations of, in pregnancy, 181
anatomy of, 46

at full term, 182
bicornis duplex, 49

pregnancy in one horn of, 282
unicollis, 49
biforis, 487

blood-vessels of, in pregnancy, 181
carcinoma of, a cause of puerperal

hemorrhage, 600
changes in form, position, and relations
of, in pregnancy, 183
in volume, capacity, and weight of,
in pregnancy, 183
conditions of, which interfere with de-
velopment of fetus, 175
congenital anomalies of, obstruction of

labor by, 484
connective tissue of, in pregnancy, 181
contraction of, after labor, method of

securing, 312
cordiformis, 49
deformities of, 49
descent of, in labor, 288, 289
development of, 41
didelphus, 49

displacement of, anterior, obstruction
of labor by, 492
as a cause of puerperal hemorrhage,

595
lateral, obstruction of labor by, 494

obstruction of labor by, 491

double, obstruction of labor by, 484

fibroid of, obstruction of labor by, 498

fibromata of, in pregnancy, 215

fixation of, obstruction of labor by, 493

hernia of, obstruction of labor by, 492,

493
incudiformis, 49

inversion of, causes of, 565

in labor, 563

symptoms of, 566

Uterus, inversion of, treatment of, 567, 568
involution of, 320. See also Involu-
tion of uterus

abnormalities of, 584
irritable, as a cause of abortion, 243
lymphatics of, in pregnancy, 1 82
muscle-fibers of, in pregnancy, 181
nerves of, in pregnancy, 182
overdistention of, a cause of labor, 287
peritoneal covering of, in pregnancy,

181
polypi of, obstruction of labor by, 501
pregnant, anteflexion of, 210

displacements of, 210

hernial protrusion of, 215

incarceration of, 211

lateral displacements of, 214

laterofiexion of, 214

lateroposition of, 214

lateroversion of, 214

prolapse of, 214

relation of, to intestines, 184

retroflexion or retroversion of, 211.
See Retroflexion

torsion of, 215
prolapse of, complication of labor by,

495
relaxation of, as a cause of puerperal

hemorrhage, 599

rapture of, 543

causes of, 543

clinical history of, 548

diagnosis of, 548

differentiation of, from accidental
hemorrhage, 549

frequency of, 543

in pregnancy, 242

morbid anatomy of, 545

prognosis of, 550

symptoms of, 548

treatment of, 551
;sacculation of, 212

obstruction of labor by, 495
semipartitus, 49
subinvolution of, 585. See Subinvih

luiion
subseptus, 49
superinvolution of, 584
unicornis, 50

pregnancy in horn of, 282

Vagina, alteration in, in pregnancy, 186
anatomy of, 45

appearance of, in pregnancy, 200
atresia of, obstruction of labor by, 489
cicatrices of, obstruction of labor by, 488
closure of, obstruction of labor by, 487
congenital narrowness of, obstruction

of labor by, 491
development of, 41

846

INDEX.

Vagina, diseases of, in pregnancy, 216
double, 50
hematomata of, obstruction of labor by,

488
laceration of, in labor, 554
microbic flora of, 662-673
micro-organisms of, 662-673
pol3rpoid hypertrophies of, in preg-
nancy, 217
septa of, obstruction of labor by, 489
tumors of, obstruction of labor by, 489
varices of, in pregnancy, 217

Vaginal enterocele, obstruction of labor

by, 503

examination for diagnosis of present-
ing part, 352
leukorrhea in pregnancy, 216
portion of uterus, 47
secretions, germicidal f>ower of, 663-

670
section for tubal pregnancy, 281
Vaginismus, obstruction of labor by, 491
Vagitus uterinus, 789
Van Huevel's method of treating fetal

hydrocephalus, 514
Varices of labia majora in pregnancy, 218

of vagina in pregnancy, 217
Varicose veins in pregnancy, 237
rupture of, 242
obstruction of labor by, 491
Variola of fetus, 158
Vegetations of vulva in pregnancy, 218
Velamentous insertion of cord, 137
Vernix caseosa, 80
Version, 754

by external manipulation, 757
cephalic, Baudelocque's method of, 376

Schatz's method of, 376
combined, 757

D'Outrepont's method of, 758
Wrights method of, 758
contraindications to, 755
in breech presentation, 387
in contracted pelves, 754
in labor with contracted pelvis, 482
in shoulder presentation, 395
indications for, 754
podalic, 757
postural, 756
sjXDntaneous, 394
Vertex presentation. See Presentation
Vesical calculi in pregnancy, 231
hemorrhoids in pregnancy, 231
Vestibule, 45
bulbs of, 45

lacerations of, in labor, 555
Villi of chorion, 103

cystic degeneration of, 104. See

Cystic (Regeneration
dropsy of, I05
of placenta, 1 12

cellular hypertrophy of, 121

Vision, disturbances of, in pregnancy,

234
Vitelline membrane, 60

Vomiting, abortion from, 24$

as an indication for inducing abortioa,

719

in pregnancy, 187, 192

pernicious, 222

causes of, 222

diagnosis of, 222

mortality from, 225

treatment of, 223

gynecological, 224

hygienic, 223

medicinal, 224

obstetrical, 225

Vulva, alterations in, in pregnancy, 186

appearance of, in pregnancy, 200

diseases of, in pregnancy, 217

edema of, in pregnancy, 218

obstruction of labor by, 490

gangrene of, obstruction of labor by,

491

in labor, 306

lacerations of, in labor, 555

pruritus of, in pregnancy, 218

vegetations of, in pregnancy, 218

Vulvovaginal glands, 45

Walcher posture, 483, 484
Wegner's sign of fetal syphilis, 1 54
Weight, changes of, in pregnancy, 187

loss of, after labor, 333

of mature fetus, 85

of new-bom infant, 789
Wet-nurse, selection of, 796
Wharton, gelatin of, 132
White pneumonia of new-born infants,

809
Wiegand's method of delivering after-
coming head, 763

treatment of placenta praevia, 533
Winckel's disease, 817
Wolffian body, 40, 41, 42

ducts, 39, 40
Womb. See Uterus
Wormian bone, obstruction of labor by,

509
Wright's method of combined version,

758

Xiphopagus, 508
birth of, 511

Yellow fever of fetus, 162
Yolk of ovum, 60

Zona pellucida of ovum, 60

CATALOGUE

OF THE

MEDICAL PUBLICATIONS

W. B. SAUNDERS & CO.,

No* 925 WALNUT STREET, PHILADELPHIA.
Aitanged Alpliabetically and Qassified under Subjects*

THE books advertised in this Catalogue as being so/tf by subscription are usually to be
obtained from travelling solicitors, but they will be sent direct from the office of pub-
lication (charges of shipment prepaid) upon receipt of the prices given. All the other
books advertised are commonly for sale by booksellers in all parts of the United States; but
books will be sent to any address, carriage prepaid, on receipt of the published price.

Money may be sent at the risk of the publisher in either of the following ways : A post-
office money order, an express money order, a liank check, and in a registered letter. Money
sent in any other way is at the risk of the sender.

See pages 32, 33 for a List of Gmteats ctasmftgid accofding to tubfeds*

LATEST PUBUCATIONS.

American Students' Medical Dictionary* See page 34.

American Text-Book of Physiology — Second (Revised) Ed* Page 7*

Friedrich and Curtis on Nose^ Throaty and Ear* See page 34*

Le Roy's Histology* See page 34*

Ogden on the Urine* See page 34*

Flic's Personal Hygiene* See page 34.

Salinger and Kalteyer's Modem Medicine* See page 34.

Stoney's Surgical Technic for Nurses* See page 34.

Hyde and Montgomery's Syphilis and Venereal Diseases — ^Revised

and Enlarged Edition* See page )5.
International Text-Book of Surgery* See page 15*
Garrigues' Diseases of Women— Third (Revised) Edition* Page J3.
American Text-Book of Dis* of Eye, Ear, Nose, and Throat* Page 5*
Saunders' American Year-Book for t900* See page 8*
Levy and Klemperer's Clinical Bacteriology* See page )7*
Scudder's Treatment of Fractures* See page 26*
Senn's Tumors — Second Edition* See page 27.
Beck on Fractures* See page 9.
Watson's Handbook for Nurses* See page 31.
Heisler's Embryology* See page 15.
Nancrede's Principles of Surgery* See page 20.
Jackson's Diseases of the Eye* See page )6.
Kyle on the Nose and Throat* See page J7.

Penrose's Diseases of Women — ^Third (Revised) Edition* Page 20.
Warren's Surgical Pathology — Second (Revised) Edition* Page 3J*
Saunder's Medical Hand-Atlases* See pages 2, 3, 4.
American Pocket Medical Dictionary— Third (Revised) Ed* Page 12.

SAUNDERS'

MEDICAL HAND-ATLASES.

The series of books included under this title consists of authorized
translations into English of the world-famous Lehmcum Medicinische
Handatlanten, which for scientific accuracy, pictorial beauty, com-
pactness, and cheapness surpass any similar volumes ever published.
Each volume contains from 50 to lOO colored plates, executed by the
most skilful German lithographers, besides numerous illustrations in the
text. There is a full and appropriate description of each plate, and
each book contains a condensed but adequate outline of the subject to
which it is devoted.

One of the most valuable features of these atlases is that thev offer a
ready and satisfactory substitute for clinical observation. To those
unable to attend important clinics these books will be absolutely indis-
pensable.

In planning this series of books arrangements were made with the rep-
resentative publishers in the chief medical centers of the world for the
publication of translations of the atlases into different languages, the litho-
graphic plates for all these editions being made in (Germany, where work of
this kind has been brought to the greatest perfection. The expense of
making the plates being shared by the various publishers, the cost to each
one was materially reduced. Thus by reason of their universal transla-
tion and reproduction, the publishers have been enabled to secure for these
atlases the best artistic and professional talent, to produce them in the
most elegant style, and yet to offer them at a price heretofore unap-
preached in cheapness. The success of the undertaking is demonstrated
by the fact that the volumes have already appeared in thirteen different
langruages — German, English, French, Italian, Russian, Spanish, Japanese,
Dutch, Danish, Swedish, Roumanian, Bohemian, and Hungarian.

In view of the striking success of these works, Mr. Saunders has con-
tracted with the publisher of the original German edition for one hun-
dred thousand copies of the atlases. In consideration of this enormous
undertaking, the publisher has been enabled to prepare and furnish special
additional colored plates, making the series even handsomer and more
complete than was originally intended.

As an indication of the practical value of the atlases and of the favor
with which they have been received, it should be noted that the Medical
Department of the U.S. Army has adopted the ** Atlas of Operative
Surgery" as its stanckird, and has ordered the book in large quantities for
distribution to the various regiments and army posts.

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Atlas and Epitome of Internal Medicine and Clinical Diagnosis.

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Atlas and Epitome of Syphilis and the Venereal Diseases. By Prof.
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Ophthalmology, Jefferson Medical College, Philadelphia. With 76
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" It is always difficult to represent pathological appearances in colored plates, but this
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VOLUMES JUST ISSUED.
Atlas and Epitome of Special Pathological Histology. By Dr. H.

DiJRCK, of Munich. Edited by Ludvig Hektoen, M. D., Professor of
Pathology, Rush Medical College, Chicago. In Two Parts. Part I.
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intestinal Tract, with 120 colored figures on 62 plates and 158 pages
of text. Price, ;i53. 00 net. Parts sold separately.

Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed.

GoLEBiEWSKi, of Berlin. Translated and edited with additions by
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Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidel-
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Prof. Dr. A. von Strumpell, of Erlangen. Edited by Edward I).
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sity and Bellevue Hospital Medical College, New York. %2> plates and
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Atlas and Epitome of Diseases of the Ear.

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Atlas and Epitome of Psychiatry.

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Atlas and Epitome of Topographical Anatomy.

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AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHILDREN.
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By 65 Eminent Contributors. Ediied by Louis Stahr, M. D.. Con-
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AN AMERICAN TEXT-BOOK OF DISEASES OF THE EVE. EAR,
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By 58 Prominent Specialists. Ediied by G. E. DE Schwf.initz. M.D ,

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6 Medical Publications of W. B. Saunders & Co.

AN AMERICAN TEXT-BOOK OP QENITO-URINARY AND SiON
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By 47 Eminent Specialists and Teachers. Edited by L. Boltok

Bangs, M. D., Professor of Genito- Urinary Surger>', University and

Bellevue Hospital Medical College, New York ; and W. A. Hard-

AWAY, M. D., Professor of Diseases of the Skin, Missouri Medical

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AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND
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AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXI-
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AN AMERICAN TEXT-BOOK OF SURGERY. Third Edition.

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London Lancet,

AN AMERICAN TEXT-BOOK OF THE THEORY AND PRACTICE
OF MEblCINE.

By 12 Distinguished American Practitioners. Edited by William
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Medical Publications of W. B. Saunders & Co. 9

BALL'S BACTERIOLOGY. Third Edition, Revised.

Essentials of BacterioIos:y ; a Concise and Systematic Introduction
to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol-
ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218
pages; 82 illustrations, some in colors, and 5 plates. Cloth, |i.oo;
interleaved for notes, $1.25.

[See Saunters* Question- Compends, page 23.]

«• The student or practitioner can readily obtain a knowledge of the subject from a perusal
ol this book. The illustrations are clear and satisfactory." — Medical Record, New York.

BASTIN'S BOTANY.

Laboratory Exercises in Botany. By Edson S. Bastin, M.A.,
late Prof, of Materia Medica and Botany, Philadelphia College of Phar-
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••It is unquestionably the best text-book on the subject that has yet appeared. The
work is eminently a practical one. We regard the issuance of this book as an important
event in the history of pharmaceutical teaching in this country, and predict for it an unquali-
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BECK ON FRACTURES.

Fractures. By Carl Beck, M.D., Surgeon to St. Mark's Hospital
and the New York German Poliklinik, etc. 225 pages, 170 illustrations.
Cloth, $3.50 net.

BECK'S SURGICAL ASEPSIS.

A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to
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BOISLINIERE*S OBSTETRIC ACCIDENTS, EMERGENCIES, AND
OPERATIONS.

Obstetric Accidents, Emergencies, and Operations. By L. Ch.

BoisLiNiERE, M.D., late Emeritus Professor of Obstetrics, St. Louis
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" A manual so useful to the student or the general practitioner has not been brought to
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BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised.

Essentials of Medical Physics. By Fred J. Brockway, M.D.,
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Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations.
Cloth, $1.00 net ; interleaved for notes, $1.25 net.

[See Saunders* Question- Compends^ page 23.]

**We know of no manual that affords the medical student a better or more concise
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10 Medical Publications of W. B. Saunders & Co.

BUTLER'S MATERIA MEDICA, THERAPEUTICS. AND PHAR-
MACOLOGY. Third Edition, Revised.
A Text-Book of Materia Medica* Therapeutics, and Pharma-
cology. By George F. Butler, Ph. G., M.D., Professor of Materia
Medica and of Clinical Medicine in the College of Ph3rsicians and
Surgeons, Chicago; Professor of Materia Medica and Therapeutics,
Northwestern University, Woman's Medical School, etc. Octavo, 874
pages, illustrated. Cloth, ^4.00 net; Sheep, J 5. 00 net.

'* Taken as a whole, the book may fairly be considered as one of the most satisfactory
of any single-volume works on materia medica in the market,** — -Journal of the American
Medical Association.

CERNA ON THE NEWER REMEDIES. Second Edition, Revised.

Notes on tlie Newer Remedies, their Therapeutic Applications
and Modes of Administration. By David Cerna, M.D., Ph.D.,
formerly Demonstrator of and Lecturer on Experimental Therapeutics
in the University of Pennsylvania ; Demonstrator of Physiology in the
Medical Department of the University of Texas. Rewritten and
greatly enlarged. Post-octavo, 253 pages. Cloth, Ji. 00 net.

•* The appearance of this new edition of Dr. Cema's very valuable work shows that it
is properly appreciated. The book ought to be in the possession of every practising physi-
cian.*' — New York Medical Journal.

CHAPIN ON INSANITY.

A Compendium of Insanity. By John B. Chapin, M.D., LL.D.,
Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi-
cian-Superintendent of the Willard State Hospital, New York ; Hon-
orary Member of the Medico-Psychological Society of Great Britain,
of the Society of Mental Medicine of Belgium. i2mo, 234 pages,
illustrated. Cloth, $1.25 net.

" The practical parts of Dr. Chapin's hook are what constitute its distinctive merit. We
desire especially to call attention to the fact that on the subject of theraj^>eutics of invinity
the work is exceedingly valuable. It is not a made book, but a genuine condensed thesis,
which has all the value of ripe opinion and all the charm of a vigorous and natural style." —
Philadelphia Medical Journal.

CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY.
Second Edition, Revised.
Medical Jurisprudence and Toxicology. By Henry C. Chap.man,

M.D., Professor of Institutes of Medicine and Medical Jurisprudence
in the Jefferson Medical College of Philadelphia. 254 pages, with 55
illustrations and 3 full-page plates in colors. Cloth, J51.50 net.

"The best book of its class for the undergraduate that we know of.'* — Xe7v York
Medical Times.

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES.
Second Edition.

Nervous and Mental Diseases. By Archibald Church, M. D.,

Prolcsscr ^i Clinical Neurology, Mental Diseases, and Medical Juris-
pnuK'iK c in the Northwestern University Medical School, Chicago;
and Fkkdkkkk Pktkrson, M. D., Clinical Professor of Mental Dis-
eases, Woman's Medical College, N. V. ; Chief of Clinic, Nervous
Dept., College of Physicians and Surgeons, N. Y. Handsome octavo
vohnne ot' 84J; pages, profusely illustrated. Cloth, $5.00 net; Half
Morocco, $6.00 wet.

Medical Publications of W* B. Saunders & Co. 11

CLARKSON'S HISTOLOGY.

A Text-Book of Histologry, Descriptive and Practical. By

Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of
Physiology in the Owen's College, Manchester; late Demonstrator of
Physiology in Yorkshire College, Leeds. Large octavo, 554 pages;
22 engravings in the text, and 174 beautifully colored original illustra-
tions. Cloth, strongly bound, ^4.00 net.

" The work must be considered a valuable addition to the list of available text books,
and is to be highly recommended." — JVinv York Medical Journal.

**This is one of the best works for students we have ever noticed. We predict that the
book will attain a well-deserved popularity among our students." — Chicago Medical Recorder,

CLIMATOLOGY.

Transactions of the Eis^hth Annual Meeting of the American
Climatolog^ical Association, held in Washington, September 22-25,
1 89 1, forming a handsome octavo volume of 276 i)ages, uniform with
remainder of series. (A limited quantity only.) Cloth, $1.50.

COHEN AND ESHNER'S DIAGNOSIS. Second Edition, Revised.

Essentials of Diag^nosis. By Solomon Solis-Cohen, M.D., Pro-
fessor of Clinical Medicine and Applied Therapeutics in the Philadel-
phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical
Medicine in the Philadelphia Polyclinic. Post-octavo, 417 pages; 55
illustrations. Cloth^ $1.00 net.

[See Saunders^ Question- Compends, page 23.]

" We can heartily commend the book to all those who contemplate purchasing a *com-
pend.' It is modern and complete, and will give more satisfaction than many other works
which are perhaps too prolix as well as behind the times." — Medical Review^ St. Louis.

CORWIN'S PHYSICAL DIAGNOSIS. Tiiird Edition, Revised.

Essentials of Physical Diag^nosis of the Thorax. By Arthur
M. CoRwiN, A.M., M. D., Demonstrator of Physical Diagnosis in Rush
Medical College, Chicago ; Attending Physician to Central Free Dis-
pensary, Department of Rhinology, Laryngology, and Diseases of the
Chest, Chicago. 219 pages, illustrated. Cloth, flexible covers, $1.25 net.

** It is excellent. The student who shall use it as his guide to the careful study of
physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good
working knowledge of the subject." — Philadelphia Polyclinic.

**A most excellent little work. It brightens the memory of the differential diagnostic
signs, and it arranges orderly and in sequence the various objective phenomena to logical
solution of a careful diagnosis." — Journal of Nen'ous and Mental Diseases,

CRAGIN'S GYN>eCOLOGY. Fourth Edition, Revised.

Essentials of Gynaecology. By Edwin B. Cragin, M. D., Lecturer

in Obstetrics, College of Physicians and Surgeons, New York. Crown
octavo, 200 pages; 62 illustrations. Cloth, 31.00 net; interleaved for
notes, Si. 25 net.

[See Saunders' Question- Compends, page 23.]

" A handy volume, and a distinct improvement on students' compends in general. No
attthor who was not himself a practical gynecolojjist could have consulted the student's needs
io thoroughly as Dr. Cragin has done.'^ — Medical Record, New York.

12 Meaical Publications of W. B. Saunders Jk Co.

CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised.

A Text-Boole of Bacteriology. By Edgar M. Crookshank, M.B.,
Professor of Comparative Pathology and Bacteriology, King's College,
London. Octavo volume of 700 pages, with 273 engravings and 22
original colored plates. Cloth, ^6.50 net; Half Morocco, I7.50 net.

" To the student who wishes to obtain a good risumi of what has been done in bacteri-
ology, or who wishes an accurate account of the various methods of research, the book maj
be recommended with confidence that he will find there what he requires." — London Lancet.

Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged.

Modern Surgery, General and Operative. By John Chalmers
DaCosta, M. D., Professor of Practic^ of Surgery and Clinical Surgery,
Jefferson Medical College, Philadelphia ; Surgeon to the Philadelphia
Hospital, etc. Handsome octavo volume of 911 images, profusely illus-
trated. Cloth, J4.00 net; Half Morocco, J5.00 net.

"We know of no small work on surgery in the English language which so well fulfils
the requirements of the modem student." — Medico-Chimrgical Joumalf Bristol, England.

DE SCHWEINITZ ON DISEASES OF THE EYE. Third EdiUon,
Revised.

Diseases of ttie Eye. A Handbook of Opfittialmic Practice.

By G. E. DE ScHWEiNiTZ, M.D., Professor of Ophthalmology in the
Jefferson Medical College, Philadelphia, etc. Handsome royal octavo
volume of 696 pages, with 256 fine illustrations and 2 chromo-litho-
graphic plates. Cloth, ^4.00 net ; Sheep or Half Morocco, J5.00 net.

** A clearly written, comprehensive manual. One which we can commend to students
as a reliable text-book, written with an evident knowledge of the wants of those entering
upon the study of this special branch of medical science." — British Medical Journal.

** A work that will meet the requirements not only of the specialist, but of the general
practitioner in a rare degree. I am satisfied that unusual success awaits it." — William
Pepper, M.D., J^rofissor of the Theory and Practice of Medicine and Clinical Mediiine,
University of Pennsylvania.

DORLAND'S DICTIONARY. Third Edition, Revised.

The American Pocket Medical Dictionary. Containing the Pro-
nunciation and Definition of all the principal words and phrases, and a
large number of useful tables. Edited by W. A. Nkwman DokL.ANn.
M. I)., Assistant Demonstrator of Obstetrics, University of Pennsylvania;
Fellow of the American Academy of Medicine. 518 pages ; handsomely
bound in full leather, limp, with gilt edges and patent index. Price,
$1.00 net; with thumb index, $1.25 net.

DORLAND'S OBSTETRICS.

A Manual of Obstetrics. By W. A. Newman Dorland, M.D.,
Assistant Demonstrator of Obstetrics, University of Pennsylvania;
Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages;
163 illustrations in the text, and 6 full-page plates. Cloth, '^2.^0 net.

** By far the l)C5t book on this subject that has ever come to our notice." — American
Medical Rnitw.

•' It lias rarely leen our duty to review a book which has given us more pleasure in its
perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowle<ige,
a gold mine of j)raclical, concise thoughts." — American Medico- Surgical Bulletin.

Medical Publications of W. B. Saunders & Co. 13

PROTHINQHAM'S GUIDE FOR THE BACTERIOLOGIST.

Laboratory Guide for the Bacteriologist. By Langdon Froth-
INGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science,
Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts.

** It is a convenient and useful little work, and will more than repay the outlay neces-
sary for its purchase in the saving of time which would otherwise be consumed in looking
np the various points of technique so clearly and concisely laid down in its pages. "— yfw^r*
can Medico- Surgical Bulletin.

GARRIGUES' DISEASES OP WOMEN. Third Edition, Revised.

Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro*
fessor of Gynecology in the New York School of Clinical Medicine ;
Gynecologist to St. Mark's Hospital and to the German Dispensary,
New York City, etc. Handsome octavo volume of 783 pages, illus-
trated by 367 engravings and colored plates. Cloth, I4.00 net;
Sheep or Half Morocco, $5.00 net.

'* One of the best text-books for students and practitioners which has been published in
the English language ; it is condensed, clear, and comprehensive. The profound learning
and great clinical experience of the distinguished author Hnd expression in this book in a
xsL<ysX attractive and instructive form. Young practitioners to whom experienced consultants
may not be available will tind in this book invaluable counsel and help." — Thad. A.
Reamy, M.D., LL.D., Professor of Clinical Gynecology ^ Medical College of Ohio,

QLEASON'S DISEASES OP THE EAR. Second Edition, Revised.

Essentials of Diseases of tlie Ear. By £. B. Gleason, S.6.,
M.D., Clinical Professor of Otology, Medico- Chi rurgical College,
Philadelphia ; Surgeon -in -Charge of the Nose, Throat, and Ear Depart-
ment of the Northern Dispensary, Philadelphia. 208 pages, with 114
illustrations. Cloth, ^i.oo net; interleaved for notes, J 1.25 net.

[See Saunders* Question- CompendSy page 23.]

** It is just the book to put into the hands of a student, and cannot fail to give him a
useful introduction to ear- affections ; while the style of question and answer which is adopted
throughout the book is, we l^lievc, the best method of impressing facts permanently on the
mind. " — Liverpool Medico- Chirurgical Journal.

GOULD AND PYLE'S CURIOSITIES OF MEDICINE.

Anomalies and Curiosities of Medicine. By George M. Gould,
M.D., and Walter L. Pyle, M.D. An encyclopedic collection of
rare and extraordinary cases and of the most striking instances of
abnormality in all branches of Medicine and Surgery, derived from an
exhaustive research of medical literature from its origin to the present
day, abstracted, classified, annotated, and indexed. Handsome im-
perial octavo volume of 968 pages, with 295 engravings in the text,
and 12 full- page plates.

popular EDITION: Cloth. $3.00 net; Half Morocco, $4.00 net.

** One of the most valuable contributions ever made to medical literature. Il is, so far
as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for
the medical profession has this volume value : it will serve as a book of reference for all who
are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical
Journal.

"This is certainly a most remarkable and interesting volume. It stands alone among
medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in
medical literature. It is a book full of revelations from its first to its last page, and cannot
but interest and sometimes almost horrify its readers." — American Medico-Surgical Bulletin,

14 Medical Publications of W. B. Saunders Jk Co.

QRAFSTROM'S MECHANO-THERAPY.

A Text-Book of Mechano-Therapy (iVlassas:e and Medical Gym-
nastics). By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in
the Royal Swedish Army ; late House Physician City Hospital, Black-
well's Island, New York. 1 2mo, 139 pages, illustrated. Cloth, ;$i.oo net.

QRIFFITH ON THE BABY. Second Edition, Revised.

The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini-
cal Professor of Diseases of Children, University of Pennsylvania ;
Physician to the Children's Hospital, Philadelphia, etc. i2mo, 404
pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50 net.

" The best book for the use of the young mother with which we are acquainted. . . .
There are very few general practitioners who could not read the book through with advan-
tage."— Archives of Pediatrics,

** The whole book is characterized by rare good sense, and is evidently written by a
master hand. It can be read with benefit not only by mothers but by medical students and
by any practitioners who have not had large opportunities for observing children." — Ameri-
can Journal of Obstetrics,

QRIFFITH'S WEIGHT CHART.

Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D. ,
Clinical Professor of Diseases of Children in the University of Penn-
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net.

GROSS. SAMUEL D.. AUTOBIOGRAPHY OF.

Autobiog^raphy of Samuel D. Gross, M. D., Emeritus Professor of
Surgery in the Jefferson Medical College, Philadelphia, with Remi-
niscences of His Times and Contemporaries. Edited by his Sons,
Samuel W. Gross, M.D., LL. D., and A. Haller Gross, A.M. Pre-
ceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D.
Two handsome volumes, over 400 pages each, demy octavo, gilt top*;,
with Frontispiece on steel. Price per volume, $2.50 net.

HAMPTON'S NURSING. Second Edition, Revised and Enlarg^ed.

Nursing: Its Principles and Practice. By Isabel .\dams Kamp
TON, Graduate of the New York Training School for Nurses attached
to Bellevue Hospital ; late Superintendent of Nurses and Principal of
the Training School for Nurses, Johns Hopkins Hospital, Baltimore,
Md. 12 mo, 512 pages, illustrated. Cloth, ^2.00 net.

" Seldom have we perused a lx)ok upon the subject that has given us so much pleasure
as the one before us. We would strongly urge u|X)n the members of our own profession the
need of a lx)ok like this, for it will enable each of us to become a training school in him-
self. ' ' — Ontario Medical Journal.

HARE'S PHYSIOLOGY. Fourtfi Edition, Revised.

Essentials of Physiology. By H. A. Hare, M.D., Professor of
Therapeutics and Materia Medica in the Jefferson Medical College of
Philadelphia. Crown octavo, 230 pages. Cloth, |i.oo net; inter-
leaved for notes, |;i.25 net.

[Sec Saunders' Question- Compcnds, page 23.]

** Tlie best condensation of physiological knowledge we have yet seen."— il/irtr'iV«i
Record, New \ oik.

Medical Publications of W. B. Saunders & Co. 15

HART'S DIET IN SICKNESS AND IN HEALTH.

Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly
Student of the Faculty of Medicine of Paris and of the London School
of Medicine for Women ; with an Introduction by Sir Henry
Thompson, F.R.C.S., M.D., London. 220 pages. Cloth, ^1.50 net.

" We recommend it cordially to the attention of all practitioners ; both to them and to
their patients it may be of the greatest service." — A^i7u York Medical JoumaL

HAYNES' ANATOMY.

A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart-
ment of the New York University, etc. 680 pages, illustrated with 42
diagrams in the text, and 134 full-page half-tone illustrations from
original photographs of the author's dissections. Cloth, $2.50 net.

" This book is the work of a practical instructor— one who knows by experience the
requirements of the average student, and is able to meet these requirements in a very satis-
factory way. The book is one that can be commended." — Medical Record^ New York.

HE1SLER*S EMBRYOLOGY.

A Text-Book of Embryology. By John C. Heisler, M.D., Pro-
fessor of Anatomy in the Medico-Chinirgical College, Philadelphia. Oc-
tavo volume of 405 pages, handsomely illustrjited. Cloth, ^2.50 net.

HIRST'S OBSTETRICS. Second Edition.

A Text-Boole of Obstetrics. By Barton Cooke Hirst, M. D.,
Professor of Obstetrics in the University of Pennsylvania. Handsome
octavo volume of 848 pages, with 618 illustrations, and 7 colored
plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net.

" The illustrations are numerous and are works of art, many of them appearing for the
first lime. The arrangement of the subject-matter, the foot-notes, and index are beyond
criticism. As a true model of what a modern text-book on obstetrics should be, we feel
justified in affirming that Dr. Hirst's book is without a rival." — New York Aledical Record.

HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL

DISEASES. Second Edition, Revised and Enlarged.

Syptiilis and the Venereal Diseases. By James Nevins Hyde,
M. D., Professor of Skin and Venereal Diseases, and Frank H. Mont-
gomery, M. D., Lecturer on Dermatology and Genito-Urinary Diseases
in Rush Medical College, Chicago, 111. Octavo, nearly 600 pages, with
14 beautiful lithographic plates and numerous illustrations.

** We can commend this manual to the student as a help to him in his study of venereal
diseases. ' ' — Liverpool Medico- Chirurgical Journal.

" The best student's manual which has appeared on the subject." — St. Louis Mtdicai
€Hd Surgical Journal.

INTERNATIONAL TEXT-BOOK OF SURGERY. In two volumes.

By American and British authors. Edited by J. Collins Warren,
M.D., LL.D., Professor of Surgery, Harvard Medical School, Boston;
and .K. Pearce Gould, M.S., F.R.C.S., Lecturer on Practical Sur-
gery and Teacher of Operative Surgery, Middlesex Hospital Medical
School, London, Eng. Vol. I. Genera i Surs^rry. — Handsome octavo,
947 pages, with 458 beautiful illustrations and 9 lithographic plates.
Vol. II. Special or Regional Sur^i^ery. — Handsome octavo, 1072 pages,
with 471 beautiful illustrations and 8 lithographic plates. Prices per
volume: Cloth, ^5.00 net; Half Morocco, ^6.00 net.

l-i Jfcriarai i^mblieations of W. B. Saunders

Xh3CSirr5 DISEASES OF THE EYE.

A Hammak id MscBSCS of tbc Eye. By Edward Jj
It. I' . ^mer.—^ Irry'xiao: O- Diseases of the Eye in th
?ii ■■:_=j; 13; Cowci* :or Graduaies in Medicine. 11
: -; :.;cr^. «--- :-- 'irdiTinil lU-iatralioiis, mostly from di

JAiHkJOfS \.\D GLEASfKV^ DISEASES OP THE EYE,
TtmaAT. SccMKi Editioa. Revised.
F*».t.a« flC Rcfndioa and Diseases of tlie Eye.
•kZir. •«, .\.>L. V. L>., Proi'essor of Diseases of the Eye

isi:i: X : ..~:-z •:. AZ-i Colles:* for Graduates in Medicio
rt*j ■■■■■< mt OUstmsts of the Nose and Tliroat.
»"?t ."•Li-».--.>" MD. . ^-^zto^-in-Cnaxg^ of the Nose,
z^iz 1 1" jr-.=e=.: zi ie Nonaem D;#[>ensar>' of Phibc
■ :i -TTif^ 7 ;-■; ■.>.-»" .v^iio, JQO pages ; 124 illustia
*■ ;j zk'. . z.-.iT-ix-'X. :"or -.otes. 51.^5 net.

■ Ci-'.V.-

t-Clr.'vjvm/Sr page 22.]

refa

K£.%TTMi'S DICTKKH.AIOr'. Second Edition. Revised.
: Oicttonary of Medicine, wii
Etymoiosy, etc 1

> ■, >1 I . Li_ D,, Fellow oi the College of Ph)-3ic
. i.-.; Hr>~y H.\v:iti3X : w:di the Lollalioraiion

.: ^-, \; !■ . ini Fbelierji_k .\. Fii^KARD, M.
: I ,---ii-- i fib-e* o: BaciU:, Micrococci,
i^?'. .-: '."ze -■ .■".-.isK ot o»"er Sao pa^e>. Prices,

= liiiv: ■;:■::-.. js.ac net: theep or Half Mc
:■.■;; ;m:s:x: l^iies: Cio:h. $4.30 net : SbeeporH

rEATlMlS I IFF IN<|-D4N-l:F

Medical Publications of W. B. Saunders dk Co. 17

KEEN ON THE SURGERY OF TYPHOID FEVER.

The Surg^ical Complications and Sequels of Typhoid Fever.

By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur-
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia;
Corresponding Member of the Soci6t6 de Chirurgie, Paris ; Honorary
Member of the Soci6t6 Beige de Chirurgie, etc. Octavo volume of
386 pages, illustrated. Cloth, I3.00 net.

•* This is probably the first and only work in the English language that gives the reader
a clear view of what typhoid fever really is, and what it does and can do to the human
organism. This book should be in the possession of every medical man in America." —
American Medico-Surgical Bulletin.

KYLE ON THE NOSE AND THROAT.

Diseases of the Nose and Throat. By D. Braden Kyle, M.D.,
Clinical Professor of Laryngology and Rhinology, Jefferson Medical
College, Philadelphia; Consulting Laryngologist, Rhinologist, and
Otologist, St. Agnes' Hospital. Handsome octavo volume of about
630 pages, with over 150 illustrations and 6 lithographic plates. Price,
Cloth, {4.00 net ; Half Morocco, ^5.00 net.

LAINE'S TEMPERATURE CHART.

Temperature Chart. Prepared by D. T. Lain^, M.D. Size 8 x 13^
inches. A conveniently arranged Chart for recording Temperature,
with columns for daily amounts of Urinary and Fecal Excretions,
Food, Remarks, etc. On the back of each chart is given in full the
method of Brand in the treatment of Typhoid Fever. Price, per pad
of 25 charts, 50 cents net.

" To the busy practitioner this chart will be found of great value in fever cases, and
especially for cases of typhoid." — Indian Lancet, Calcutta.

LEVY AND KLEMPERER'S CLINICAL BACTERIOLOGY.

The Elements of Clinical Bacteriology. By Dr. Ernst Levy, Profes-
sor in the University of Strassburg, and Fklix Klemperer, Privat decent
in the University of Strassburg. Translated and edited by Augustus
A. EsHNER, M.D., Professor of Clinical Medicine in the Philadelphia
Polyclinic. Octavo, 440 pages, fully illustrated. Cloth, $2.50 net.

LOCKWOOD'S PRACTICE OF MEDICINE.

A Manual of the Practice of Medicine. By George Roe Lock*
WOOD, M.D., Professor of Practice in the Woman's Medical College
of the New York Infirmary, etc. 935 pages, with 75 illustrations in
the text, and 22 full-page plates. Cloth, $2.50 net.

" Gives in a most concise manner the points essential to treatment usually enumeratec
in the most elaborate works." — Massachusetts Medical Journal.

LX)NQ'S SYLLABUS OF GYNECOLOGY.

A Syllabus of Gynecolog^y, arranged in Conformity with •• An
American Text-Book of Gynecology." By J. W. Long, M.D.,
Professor of Diseases of Women and Children, Medical College of
Virginia, etc. Cloth, interleaved, Ji.oo net.

" The book is certainly an admirable risumi of what every gynecological student anH
practitioner should k»ow, and will prove of value not only to those who have the * Americar
Text- Book of Gynecology,' but to others as well." — Brooklyn Medical Journal.

»-■»: ^5!orrrs pathologic

Medical Publications of W. B. Saunders iS: Co. 19

McFARLAND'S PATHOGENIC BACTERIA. Second EdiUon, Re-
vised and Greatly Enlars:ed.

Text-Book upon the Pathogenic Bacteria. By Joseph McFar-
LAND, M. D., Professor of Pathology and Bacteriology in the Mcdico-
Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages,
finely illustrated. Cloth, I2.50 net.

'* Dr. McFarland has treated the subject in a systematic manner, and has succeeded in
presenting in a concise and readable form the essentials of bacteriology up to date. Alto-
gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the
students of Trinity College."— H. B. Anderson, M.D., Professor of Paihoiogy and Bac*
teriologVf Trinity Alfdical Coiifgf, Toronto,

MEIGS ON FEEDING IN INFANCY.

Feeding: in Early Infancy. By Arthur V. Meigs, M.D. Bound
in limp cloth, flush edges, 25 cents net.

" This pamphlet is worth many times over its price to the physician. The author*!
experiments and conclusions are original, and have been the means of doing much good.*'—
Medical Bulletin.

MOORE'S ORTHOPEDIC SURGERY.

A Manual of Orthopedic Surgery. By James £. Moore, M.D.,
Professor of Orthopedics and Adjunct Professor of Clinical Surgery,
University of Minnesota, College of Medicine and Surgery. Octavo
volume of 356 pages, handsomely illustrated. Cloth, ^2.50 net.

"A most attractive work. The illustrations and the care with which the book is adapted
to the w^ants of the general practitioner and the student are worthy of great praise.'* — Chicago
Medical Recorder.

** A very demonstrative work, every illustration of which conveys a lesson. The work is
a most excellent and commendable one, which we can certainly endorse with pleasure.**—-
St. Louis Medical and Surgical Journal.

MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth
Edition, Revised.

Essentials of Materia Medica, Therapeutics, and Prescription-
Writing. By Henry Morris, M.D., late Demonstrator of Thera-
peutics, Jefferson Medical College, Philadelphia, Fellow of the College
of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth,
J I. GO net; interleaved for notes, $1.25 net.

[See Saunders* Question- Compends, page 22.]

"This work, already excellent in the old edition, has been largely improved by revi*
sioD.*' — American Practitioner and News.

MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE.
Third Edition, Revised.

Essentials of the Practice of Medicine. By Henry Morris, M. D.,
late Demonstrator of Therapeutics, Jefferson Medical College, Phila-
delphia ; with an Appendix on the Clinical and Microscopic Examina-
tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry,
Jefferson Medical College, Philadelphia. Enlarged by some 300 essen-
tial formulae collected and arranged by William M. Powell, M.D.
Post-octavo, 488 pages. Cloth, 31.50 net.

[See Saunders' Question- Compends, page 22.]

" The teaching is sound, the presentntinn graphic ; mniitr full as can be desired, «uid
j«tyle attractive." — American Practitio:i<r and aXcws,

20 Medical Publications of W. B. Saunders A Co.

— , - ■ ■ ■ - - - ^ .»

MORTEN'S NURSE'S DICTIONARY.

Nurse's Dictionary of Medical Terms and Nursinj^ Treat-
ment. Containing Definitions of the Principal Medical and Nursing
Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci-
dents, Treatments, Operations, Foods, Appliances, etc. encountered
in the ward or in the sick-room. By Honnor Morten, author of
** How to Become a Nurse," etc. i6mo, 140 pages. Cloth, ^i. 00 net.

*• A handy, compact little volume, containing a lai^e amount of general information, all
of which is an-anged in dictionary or encyclopedic form, thus facilitating quick reference.
It is certainly of value to those for whose use it is published." — Chicago Clinical Review.

NANCREDE'S ANATOMY. Sixth Edition, Thoroughly Revised.

Essentials of Anatomy, including the Anatomy of the Viscera.
By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and
of Clinical Surgery in the University of Michigan, Ann Arbor. Crown
octavo, 420 pages; 151 illustrations. Based upon Gray's Analomy,
Cloth, $1.00 net ; interleaved for notes, $1.25 net.

[See Saunders' Question- Compends^ page 23.]

** For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at
school, it would not be easy to speak of it in terms too favorable.** — American Practitioner,

NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition.

Essentials of Anatomy and Manual of Practical Dissection.

By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of
Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo ;
500 pages, with full-page lithographic plates in colors, and nearly 200
illustrations. Extra Cloth (or Oilcloth for dissection-room), ^2.00 net.

** It may in many respects be considered an epitome of Gray's popular work on general
anatomy, at the same lime having some distinguishing characteristics ol its own to commend
II The plates are of more tlian ordinary excellence, and are of es|)ecial value to students
in their work in the dissecting room." — Journal rf the American Medical Association.

NANCREDE'S PRINCIPLES OF SURGERY.

Lectures on the Principles of Surgery. By Chas. B. Nancrede,
M.D , LL.D., Professor of Surgery and of Clinical Surgery, Univer-
sity of Michigan, Ann Arbor. Octavo volume of 398 pages, illustrated.
Cloth, $2.50 net.

NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised.

Syllabus of Obstetrical Lectures in the Medical Department
of the University of Pennsylvania. By Richard C. Norkis,
A.M., M.D., Demonstrator of Obstetrics, University of Penns)lvania.
Crown octavo, 222 j)ages. Cloth, interleaved for notes, $2.00 net.

PENROSE'S DISEASES OF WOMEN. Third Edition, Revised.

A Text-Book of Diseases of Women. By Charles B. Penk(^>f.
M. I)., Ph. ])., Formerly Professor of Gynecology in the University
of Pennsylvania ; Surgeon to the (iynerean Hospital, Philadcli)hia.
Octavo volume of 531 i)ages, hand.somely illustrated. Cloth, $3.75 net.

•• T shall value very highly the copy of Penrose's 'Diseases of Women* received.
1 have already recominended it to my class as THE BEST book." — Howard A. Kellv.
Proffssor of Gynecolo;^y and Obstetri:s^ Johns Hopkins Untverfity\ Bal/iruo> <», Md.

Medical Publications of W. B. Saunders & Co. 21

POWELL'S DISEASES OF CHILDREN. Second Edition.

Essentials of Diseases of Children. By William M. Powell,
M.D., Attending Physician to the Mercer House for Invalid Women
at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of
Children in the Hospital of the University of Pennsylvania. Crown
octavo, 222 pages. Cloth, $i.oo net; interleaved for notes, $1.25 net.

[See Saunders' Question- Compends^ page 21.]

"Contains the gist of all the best works in the department to which it relates."-*
American Practitioner and News,

PRINQLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS.

Pictorial Atlas of SIcin Diseases and Syphilitic Affections
(American Edition). Translation from the French. Edited by
J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex
Hospital, London. Photo-lithochroraes from the famous models in
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-
cuts and text. In 12 Parts. Price per Part, $3.00. Complete in
one volume, Half Morocco binding, $40.00 net.

«* I strongly recommend this Atlas. The plates are exceedingly well executed, and
will be of great value to all studying dermatology." — Stephen Mackenzie, M.D.

' * The introduction of explanatory wood-cuts in the text is a novel and most important
feature which greatly furthers the easier understanding of the excellent plates, than which
nothing, we venture to say, has heen seen better in point of correctness, beauty, and general
merit." — New York Medical Journal,

PRYOR— PELVIC INFLAMMATIONS.

The Treatment of Pelvic Inflammations through the Vas^ina.

By W. R. Pryor, M.D., Professor of Gynecology in New York Poly-
clinic. i2mo, 248 pages, handsomely illustrated. Cloth, |2.oo net.

*< This subject, which has recently been so thoroughly canvassed in high gynecological
circles, is made available in this volume to the general practitioner and student. Nothing is
too minute for mention and nothing is taken for granted ; consequently the book is of the utmost
value. The illustrations and the technique are beyond criticism." — Chicago Medical Recorder.

PYE'S BANDAGING.

Elementary Bandaging and Surgical Dressing. With Direc-
tions concerning the Immediate Treatment of Cases of Emergency.
For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late
Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80
illustrations. Cloth, flexible covers, 75 cents net.

•* The directions are clear and the illustrations are good.*' — London Lancet,

** The author writes well, the diagrams are clear, and the hnxik itself is small and port-
able, although the paper and type are good." — British Medical Journal.

RAYMOND'S PHYSIOLOGY.

A Manual of Physiology. By Joseph H. Raymond, A.M., M.D.,
Professor of Physiology and Hygiene and Lecturer on Gynecology in
the Long Island College Hospital ; Director of Physiology in the
Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the
text, and 4 full-page colored plates. Cloth, $1.25 net.

" Extremely well gotten up, and the illustrations have been selected with care. The
text is fully abreast with modem physiology." — British Medical Jourtial,

Saundei^'
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^ OVER 175,000 COPIES SOLD. ^
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c guard of "Siudeni's Helps "— that n'> KKi.p, They ue the
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the selection of authors is fully demantlrated by their profculoiul

inding. Chosen from the ranks o{ Demonstialors, Quii-niasteis, and Ai&islants, nwu.
ihem hare become Protcssora and Lecturers in their respective eoUeg<

Each book is of conTcnient sbe (5X 7 iochea), containing on an aTrrage ajO
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The entire series, numbering Iwtnly-three volumes, has been kept iboroagUy
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TO SUM UP.

Although there are
them approach the " Blue Series of Qi
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2. Conciscuess, clearness, and soundn<
J. Quality of illustrations, paper, printing, and binding.

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" Where the work of preparing students* manuals is to end we cannot say, but the
Saunders Series, in our opinion, bears off the palm at present."— Aiew yark Medical Record,

1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition,

revised and enlarged.

2. ESSENTIALS OF SURGERY. By Edward Martin, M. D. Seventh edition,

revised, virith an Appeiulix and a chapter on Appendicitis.

3. ESSENTIALS OF ANATOMY. By Chari.es B. Nancrede, M.D. Sixth

edition, thoroughly revised and enlarged.

A. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC.

By Lawrence Wolff, M.D. Fifth edition, revised.

5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth

edition, revised and enlarged.

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E.

Armand Semple, M. D.

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE-

SCRIPTION-WRITING. By Henry Morris, M.D. Fifth edition, revised.

8,9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris,
M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D.
Third edition, enlarged by some 300 Essential Formula*, selected from eminent
authorities, by Wm. M. Powell, M.D. (Double number, ^^1.50 net.)

10. ESSENTIALS OF GYN/ECOLOGY. By Edwin B. Cragin, M.D. Fourth

edition, revised.

11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon,

M.D. Fourth edition, revised and enlarged.

12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL

DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged.

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.

By C. E. Armand Semple, M.D.

H. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT.

By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised.

15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell,

M. D. Second edition.

16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff,

M.D. Colored ** Vogel Scale." (75 cents net.)

17. ESSENTIALS OF DIAGNOSIS. By S. Sous Cohen, M.D., and A. A. Eshner,

M.D. Second eciition, thoroughly revised.

18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre.

Second edition, revised and enlarged.

20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition,

revised.

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C

Shaw, M. D. Third edition, revised.

22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D.

Second edition, revised.

23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D.,

and Edward S. Lawra.nce, M.D.

24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D.

Second edition, revised and greatly enlarged.

Pamphlet containing specimen pages, etc* sent free iipoa appttcatioQ,

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^T'HAT there existi a need for Ibmoughly reliable hand-books on the leading branches
of Medicine and Surgery is a fact amply demoostraled by the favor with whkh
the SAUNDERS NEV SERIES OF MANUALS have been received by medical
itudents and practitioners and by the Medical Press. These manuals are not njerely
condensations from presenl lileralure, but are ably written by well-known authon
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Each volume is concisely and a ulhorita lively written and enhaustive in detail, wllbout
being encumbered with the introduction of "cases," which so largely expand the
ordinary text-book. These manuals will therefore form an admirable collection d
advanced lectures, useful alike to the medical student and the practitioner: to the
latter, loo busy to search through page alter page of elaborale treatises for what be
wants to know, they will prove of inestimable value ! 10 liie former they will afford
cafe ^ides to the essential points of study.

The SAUNDERS NEV SERIES OF MANUALS are conceded to be tupaicr
to any timilat books now on the market. No otbei manuals afford so much infoi^
oution in such a concise and available form. A liberal expenditure has enabled the
publisher to render the mechanical portion of the work worthy of the high litowy
itaodard attained by tfiese books.

Any of tfiese Manuals will be mailed on receipt of price (see next pace for

Saunders^ New Scries of Manuak*

VOLUMES PUBLISHED.

PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology
and Hygiene and Lecturer on Gynecology in the Ix>ng Island College Hospital ;
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, 3i-25 neL

SURGERY, General and Operative. — By John Chalmkrs DaCosta, M. D., Pro-
fessor of Practice of Surgery and Clinical Surgery, Jefferson Medical College, Philadel-
phia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised
and greatly enlarged. Octavo, 911 pages, profusely illustrated. Cloth, ;S4.oo net;
Half Morocco, $5.00 net.

DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q.

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila-
delphia. Illustrated. Cloth, $1.25 net.

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospiul and
to the New York German Poliklinik, etc. Illustrated. Cloth, ^^1.25 net.

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of InsU-
tutcs of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila*
delphia. Illustrated. Cloth, $1.50 net.

SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D.,
Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D.,
Lecturer on Dennatology and Genito-Urinnry Diseases in Rush Medical College,
Chicago. Second edition, thoroughly revised and greatly enlarged.

PRACTICE OF MEDICINE. By George Roe Lockwood, M.D.. Professor of
Practice in the Woman's Medical College of the New York Infirmary ; Instructor in
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated.
Cloth, $2.50 net.

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of
Anatomy and Demot^strator of Anatomy, Medical Department of the Ne'* YofK
University, etc. Beautifully illustrated. Cloth, I2.50 net

MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant
Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis-
pensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, ^2.50 net.

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to
Middlesex Hospital and Surgeon to Chelsea Hospital, Ix>ndon ; and Arthur E.
CiILES, M. D., B. Sc. I^nd., F.R.C.S. Edin., Assistant Surgeon to Chelsea Piospital,
London. Handsomely illustrated. Cloth, $2.50 net.

VOLUMES IN PREPARATION.

NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous
Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopaedic
Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph
Hospital, etc.

%* There will be published in the same series, at short intervals, carefully-prepared woite
OD various subjects by prominent specialists.

Pamphlet contalniiig ipedmen pages, etc* leot free upon applkatiocu

26 Medical Publications of W. B. Saunders & Co.

SAUNDBY'S RENAL AND URINARY DISEASES.

Lectures on Renal and Urinary Diseases. By Robert Saundby,
M.D. Ekiin., Fellow of the Royal College of Physicians, London, and
of the Royal Medico-Chirurgical Society ; Physician to the General
Hospital ; Consulting Physician to the Eye Hospitai and to the Hos-
pital for Diseases of Women; Professor of Medicine in Mason College,
Birmingham, etc. Octavo volume of 434 pages, with numerous illus-
trations and 4 colored plates. Cloth, $2.50 net.

** The volume makes a favorable impression at once. The style is clear and succinct.
We cannot find any part of the subject in which the views expressed are not carefully thought
out and fortiBed by evidence drawn from the most recent sources. The book may be cordially
recommended." — British Medical Journal,

SAUNDERS' MEDICAL HAND-ATLASES.

For full description of this series, with list of volumes and prices, see
page 2.

*' Lehmann Medicinische Handatlanten belong to that class of books that are too good
to be appropriated by any one nation." — youmal of Eyc^ Ear^ and Throat Diseases.

*' The appearance of these works marks a new era in illustrated English medical
works." — The Canadian Practitioner.

SAUNDERS' POCKET MEDICAL FORMULARY. Sixth Edition,

Revised.

By William M. Powell, M.D., Attending Physician to the Mercer
House for Invalid Women at Atlantic City, N. J. Containing 1800
formulae selected from the best-known authorities. With an Appen-
dix containing Posological Table, Formulae and Doses for Hypo-
dermic Medication, Poisons and their Antidotes, Diameters of the
Female Pelvis and Fcetal Head, Obstetrical Table, Diet List for Various
Diseases, Materials and Drugs used in Antisei)tic Surgery, Treatment
of Asphyxia from Drowning, Surgical Remembrancer, Tables of
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand-
somely bound in flexible morocco, with side index, wallet, and flap.
^1.75 net.

** This little book, that can be conveniently carried in the pocket, contains an immense
amount of material. It is ver}' useful, and, as the name of the author of each prescription
is given, is unusually reliable." — Medical Record^ New York.

SAYRE'S PHARMACY. Second Edition, Revised.

Essentials of the Practice of Pharmacy. By Lucius E. Sayre,
M.D., Professor of Pharmacy and Materia Medica in the University of
Kansas. Crown octavo, 200 pages. Cloth, $1.00 net; interleave< for
notes, $1.25 net.

[See Saunders' Question- Comperids, page 21.]

•* The topics are treated in a simple, practical manner, and the work forms a very usefuJ
student's manual." — Boston Medical and Surgical Journal.

SCUDDER'S FRACTURES.

The Treatment of Fractures. By Chas. L. Scudder, M.D., .\s-
sistaiu in Clinical and Operative Surgery, Harvard Medical School.
Octavo, 433 P^^g^'N with nearly 600 original illustrations. Cloth, $4.50
net.

^ Medical Publications of W. B. Saunders A Co. 27
•4

\^SBMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.

< Essentials of Legal Medicine, Toxicology, and Hygiene. By

^ C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lend.,

Physician to the Xortheastem Hospital for Children, Hackney, etc.
Crown octavo, 212 pages; 130 illustrations. Cloth, $1.00 net; inter-
leaved for notes, $1.25 net.

[See Saunders' Question- Compends, page 21.]

** No general practitioner or student can afford to be without this valuable work. The
subjects are dealt with by a masterly hand.*' — London Hospital GaxetU.

SEMPLE'S PATHOLOGY AND MORBID ANATOMY.

Essentials of Pathology and Morbid Anatomy. By C. £.

Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to
the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 1 74
pages; illustrated. Cloth, $1.00 net; interleaved for notes, §1.25 nn.

[See Saunders'^ Question- Compends, page 21.]

" Should take its place among the standard volumes on the bookshelf of both student
and practitioner.'* — London Hospiial Gazitte.

SENN'S GENITO-URINARY TUBERCULOSIS.

Tuberculosis of the Qenito-Urinary Organs, Male and Female.

By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of
Surgery and of Clinical Surgery, Rush Medical College, Chicago.
Handsome octavo volume of 320 phages, illustrated. Cloth, $3.00 net.

*• An important book upon an important subject, and written by a man of mature judg-
ment and wide experience. The author has given us an instructive book upon one of the
most important subjects of the day." — Clinical Reporter.

** A work which adds another to the many obligations the profession owes the talented
author.*' — Chicago Medical Recorder.

SENN'S SYLLABUS OF SURGERY.

A Syllabus of Lectures on the Practice of Surgery, arranged
in conformity with «• An American Text-Book of Surgery.*' By

NicHOL.vs Seen*, M. D., Ph.D., Professor of the Practice of Siirger}- and
of Clinical Surger)*, Rush Medical College, Chicago. Cloth, $1.50 net.

" This syllabus will be found of service by the teacher as well as the student, the work
being superbly done. There is no praise too high for it. No surgeon should be without
it." — Xew York Medical Times.

SENN*S TUMORS. Second Edition. Revised.

Pathology and Surgical Treatment of Tumors. P>y N. Senn,
M.l), Ph.D., LL.D., Professor of Surgery and of Clinical Surgery,
Rush Medical College : Professor of Surgery, Chicago Polyclinic ;
Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St.
Joseph's Hospital, Chicago. Second Editiofu Thoroui^hly Revised. Oc-
tavo volume of 718 pages, with 478 illustrations, including 12 full-|>age
plates in colors. Prices: Cloth, ;S5.oo net : Half Morocco, $6.00 net.

** The most exhaustive of any recent book in English on this subject. It is well illus-
trated, and will doubtless remain as the principal monograph on the subject in our language
for some years. The Uxik is handsomely illustrated and printed, and the author has given Ji
notable and lasting contribution to surgery." — Journal of tht American Medical Association,

28 Medical Publications of W. B. Saunders A Co.

SHAW'S NERVOUS DISEASES AND INSANITY. Third Editioo,
Revised.

Essentials of Nervous Diseases and Insanity. By John C.
Shaw, M. D., Clinical Professor of Diseases of the Mind and Nervous
System, Long Island College Hospital Medical School; Consulting
Neurologist to St. Catherine's Hospital and to the Long Island College
Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth,
1 1. 00 net ; interleaved for notes. Si. 25 net.

[See Saunders* Question- Compends, page 21.]

"Clearly and intelligently written." — Boston MedUal and Surgical Journal.

"There is a mass of valuable material crowded into this small compasa." — American
Medico- Surgical Bulletin.

STARR'S DIETS FOR INFANTS AND CHILDREN.

Diets for Infants and Children in Health and in Disease. By

Louis Starr, M.D., Editor of '*An American Text-Book of the
Diseases of Children.** 230 blanks (pocket-book size), perforated
and neatly bound in flexible morocco. J1.25 net.

The first series of blanks are prepared for the first seven months of infant life ; each
blank indicates the ingredients, but not the quantities, of the food, the latter directions being
left for the physician. After the seventh month, modifications being less necessary, the diet
lists are printed in full. Formulae for the preparation of diluents and foods are appended.

STELWAQON'S DISEASES OF THE SKIN. Fourth Ed., Revised.

Essentials of Diseases of the Skin. By Henry W. Stelwagon,
M.D., Clinical Professor of Dermatology in the Jefferson Medical
College, Philadelphia; Dermatologist to the Philadelphia Hospital;
Physician to the Skin Department of the Howard Hospital, etc.
Crown octavo, 276 pages; %% illustrations. Cloth, $1.00 net; inter-
leaved for notes, $1.25 net.

[See Saunders* Question- Compends, page 21.]

** The best student's manual on skin diseases we have yet seen." — Times and Register.

STENGEL'S PATHOLOGY. Second Edition.

A Text- Book of Pathology. By Alfred Stengel, M.D., Professor
of Clinical Medicine in the University of Pennsylvania; Physician to
the Philadel])hia Ho.s])ital ; Physician to the Children's Hospital, etc.
Handsome octavo volume of 848 pages, with nearly 400 illustrations,
many of them in colors. Cloth, $4.00 net; Half Morocco, $5.00
net.

STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second
Edition, Revised.
A Manual of Materia Medica and Therapeutics. By A. A.

Stevi-ns, A.m., M.l)., Lecturer on Terminology and Instructor in
Physical I )iagnosis in the University of Pennsylvania ; Professor of
Pathology in the Woman's Medical College of Pennsylvania. Post-
0( lavo, 445 j)aL,^es. Mexible leather, S2.00 net.

•* The niitl)or has faithfully presented modern thera{)eutics in a comprehensive work,
and, while intended j)articulariy for the use of students, it will be found a reliable guide and
sufficiently comprehensive for the physician in practice.'' — University Medical Magazine.

1 .

Medical Publications of W. B. Saunders & Co. 29

STEVENS* PRACTICE OF MEDICINE. Fifth EdiUon, Revised.
A Manual of tiie Practice of Medicine. By A. A. Stevens, A. M.,
M. D., Lecturer on Terminology and Instructor in Physical Diagnosis
in the University of Pennsylvania; Professor of Pathology in the
Woman's Medical College of Pennsylvania. Specially intended for
students preparing for graduation and hospital examinations. Post-
octavo, 519 pages; illustrated. Flexible leather, |2.oo net.

'< The frequency with which new editions of this manual are demanded bespeaks its
popularity. It is an excellent condensation of the essentials of medical practice for the
student, and may be found also an excellent reminder for the busy physician." — BuffaU
Medical Journal.

STEWART'S PHYSIOLOGY. Third Edition, Revised.

A Manual of Physiology, with Practical Exercises. For
Students and Practitioners. By G. N. Stewart, M.A., M.D.,
D.Sc, lately Examiner in Physiology, University of Aberdeen, and
of the New Museums, Cambridge University ; Professor of Physiology
in the Western Reserve University, Cleveland, Ohio. Octavo volume
of 848 pages; 300 illustrations in the text, and 5 colored plates.
Cloth, $3.75 net.

« It will malce its way by sheer force of merit, and amply deserves to do so. It is one
of the very best English text-books on the subject." — London Lancet.

**Of the many text- books of physiology published, we do not know of one that so
nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal,

STEWAliT AND LAWRANCE*S MEDICAL ELECTRICITY.

Essentials of Medical Electricity. By D. D. Stewart, M.D.,
Demonstrator of Diseases of the Nervous System and Chief of the
Neurological Clinic in the Jefferson Medical College; and E. S.
Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon-
strator of Diseases of the Nervous System in the Jefferson Medical
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth,
^i.oo net; interleaved for notes, J 1.2 5 net

[See Saunders* Question- Campends^ page 21.]

'* Throughout the whole brief space at their command the authors show a discrininating
knowledge of their subject." — Medical News.

STONEY'S NURSING. Second Edition, Revised.

Practical Points in Nursing. For Nurses in Private Practice.

By Emily A. M. Stoney, Graduate of the Training-School for Nurses,
Lawrence, Mass.; late Superintendent of the Training-School for
Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated
with 73 engravings in the text, and 8 colored and half-tone plates.
Cloth, $1.75 net.

" There are few books intended for non-professional readers which can be so cordially
endorsed by a medical journal as can this one." — Therapeutic Gazette.

" This is a well- written, eminently practical volume, which covers the entire range of
private nursing as distinguished from hospital nursing, and instructs the nurse how best to
meet the various emergencies which may arise, and how to prepare everything ordinarily
needed in the illness of her patient.'* — American Journal of Obstetrics and Diseases of
Women and Children.

** It is a work that the physician can place in the hands of his private nurses with thf
Assurance of benefit." — Ohio Medical Journal,

30 Medical Publications of W. B. Saunders & Co.

STONEY*S MATERIA MEDICA FOR NUR5E&

Materia Medica for Nurses. By Emily A. M. Stoney, Graduate of
the Training-School for Nurses, Lawrence, Mass. ; late Superintendent
of the Training-School for Nurses, Carney Hospital, South Boston, Mass.
Handsome octavo volume of 306 pages. Cloth, $1.50 net.

The present book diflfers from other similar works in several features, all of which are
intended to render it more practical and generally useful. The general plan of the contents
follows the lines laid down in training-schools for nurses, but the book contains much use*
ful matter not usually included in works of this character, such as Poison-emergencies,
Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms
used in Materia Medica, and describing all the latest drugs and remedies, which have been
generally neglected by other books of the kind.

SUTTON AND GILES' DISEASES OF WOMEN.

Diseases of Women, By J. Bland Sution, F.R.C.S., Assistant
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital,
London ; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin.,
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand-
somely illustrated. Cloth, ^2.50 net.

"The text has been carefully prepared. Nothing essential has been omitted, and its
teachings are those recommended by the leading authorities of the day.'* — Jonmal of th4
American Medical Association.

THOMAS'S DIET LISTS. Second Edition, Revised.

Diet Lists and Siclc-Room Dietary. By Jerome B. Thomas,
M.p., Visiting Physician to the Home for Friendless Women and
Children and to the Newsboys' Home ; Assistant Visiting Physician to
the Kings County Hospital. Cloth, $1.25 net. Send for sample sheet.

THORNTON'S DOSE-BOOK AND PRESCRIPTION-WRITING.

Dose-Boole and Manual of Prescription-Writing. By E. Q.

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical
College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net.

"Full of practical suggestions; will take its place in the front rank of works of ihb
jort. " — Medical Record^ New York.

VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH.
Diseases of the Stomacii. By William W. Van Valzah, M.D.,

Professor of General Medicine and Diseases of the Digestive System
and the Blood, New York Polyclinic ; and J. Douglas Nisbet, M.D.,
Adjunct Professor of General Medicine and Diseases of the Digestive
System and the Blood, New York Polyclinic. Octavo volume of 674
pages, illustrated. Cloth, $3.50 net.

" Its chief claim lies in its clearness and general adaptability to the practical needs of
the general |)ractitioner or student. In these relations it is probably the best of the recent
special works on diseases of the stomach." — Chicago Clinical Review.

VECKrS SEXUAL IMPOTENCE.

The Patholog^y and Treatment of Sexual Impotence. By Victor
G. Vf.cki, M.D. From the second German edition, revised and en-
larged. Demi -octavo, 291 pages. Cloth, ^2.00 net.

Tlie subject of imjx)tcnce has seldom been treated in this country in the truly scientific
Hr»rit that it deserves. Dr. Vecki's work has long been favorably known, and the Geiman
txx>k has received the highest consideration. This edition is more than a mere translation,
lor, although based on the German edition, it has been entirely rewritten in English.

Medical Publications of W. B. Saunders & Co. 31

VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised.

Medical Dias:nosis. By Dr. Oswald Vierordt, Professor of Medi-
cine at the University of Heidelberg. Translated, with additions,
from the fifth enlarged German edition, with the author's permission,
by Francis H. Stuart, A. M., M.X). Handsome royal octavo volume
of 603 pages; 194 fine wood-cuts in text, many of them in colors.
Cloth, ^4.00 net; Sheep or Half Morocco, $5.00 net.

** Rarely is a book published with which a reviewer can find so little fault as with the
volume before us. Each particular item in the consideration of an organ or apparatus, which
is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing
seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and
nervous system are especially full and valuable. The reviewer would repeat that the book is
one of the best — probably ihf best — which has fallen into his hands." — University Afedicai
Magazine.

WATSON'S HANDBOOK FOR NURSES.

A Handbook for Nurses. By J. K. Watson, M.D., Edin. Ameri-
can Edition, under supervision of A. A. Stevens, A.M., M.D., Lecturer
on Physical Diagnosis, University of Pennsylvania. i2mo, 413 pages,
73 illustrations. Cloth, S1.50 net.

WARREN'S SURGICAL PATHOLOGY. Second Edition.

Surs:ical Pathology and Therapeutics. By John Collins Warren,
M.D., LL.D., Professor of Surgery, Harvard Medical School. Hand-
some octavo, 832 pages ; 136 relief and lithographic illustrations, 33 in
colors; with an Appendix on Scientific Aids to Surgical Diagnosis, and
a series of articles on Regional Bacteriology. Cloth, I5.00 net; Half
Morocco, 56.00 net.

** A most striking and very excellent feature of this book is its illustrations. Without
exception, from the point of accuracy and artistic merit, they are the best ever seen in a work
of this kind. Many of those representing microscopic pictures are so perfect in their coloring
and detail as almost to give the beholder the impression that he is looking down the barrel
of a microscope at a well -mounted section." — Annals of Surgery.

WOLFF ON EXAMINATION OF URINE.

Essentials of Examination of Urine. By Lawrence Wolff, M.D.,
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia,
etc. Colored (Vogel) urine scale and numerous illustrations. Crown
octavo. Cloth, 75 cents net.

[See Saunders' Question- Compends, page 21.]
" A very good work of its kind— very well suited to its purpose. "— TiWj a«</ Register.

WOLFF'S MEDICAL CHEMISTRY. Fifth Edition, Revised.

Essentials of Medical Cliemistry, Org^anic and Inors:anic.

Containing also Questions on Medical Physics, Chemical Physiology,
Analytical Processes, Urinalysis, and Toxicology. By Lawrence
Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College,
Philadelphia, etc. Crown octavo, 222 pages. Cloth, ^i.oo net; inter-
leaved for notes, ^1.25 net.

[See Saunders' Question- Compends, page 21.]

' * The scope of this work is certainly equal to that of the best course of lectures on
Medical Chemistry." — Fhannaceutical Era.

CLASSIFIED LIST

OF THE

Medical Publications

W- B* SAUNDERS & COMPANY,

925 Walnut Street, Philadelphia.

ANATOMY, EMBRYOLOGY,
HISTOLOQY.

Clarkson — A Text- Book of Histology, 1 1

Haynes — A Manual of Anatomy, . . . 15

Heisler — A Text- Book of Embryology, 15

Nancrede — Essentials of Anatomy, . . 20
Nancrede^ — Essentials of Anatomy and

Manual of Practical Dissection, ... 20

Semple — Essentials of Pathology, . . 27

BACTERIOLOGY.

Ball — Elssentials of Bacteriology, ... 8
Crookshank^A Text-Book of Bacteri-
ology, 12

Prothingham— Laboratory Guide, . . 13
Levy and Klemperer's Clinical Bacte-
riology, 17

Malloxy and Wright — Pathological

Technique, 18

McParland — Pathogenic Bacteria, . . 19

CHARTS, DIET-LISTS, ETC.

Griffith— Infant's Weight Chart, ... 14

Hart — Diet in Sickness and in Health, . 15

Keen — Operation Blank, 17

Lain6 — Temperature Chart, • '7

Meigs — Feeding in Early Infancy, . . 19

Starr — Diets for Infants and Children, . 28

Thomas — Diet-Lists 30

CHEMISTRY AND PHYSICS.

Brockway — Essentials of Medical Phys-
ics, 9

Wolff — Essentials of Medical Chemistry, 3 1

CHILDREN.

An American Text-Book of Diseases

of Children, . . 5

Griffith — Care of the Baby, 14

Griffith — Infant's Weight Chart, ... 14

Meigs — Feeding in Early Infancy, . . 19

Powell — Essentials of Dis. of Children, 21

Starr — Diets for Infants and Children, . 28

DIAGNOSIS.

Cohen and Eshner— Essentials of Di-
agnosis,

Corwin — Physical Diagnosis, ....

Macdonald — Surgical Diagnosis and \
Treatment,

Vierordt— Medical Diagnosis, . . .

DICTIONARIES.

Borland— Pocket Dictionarv, . . .

Keating — I'ronouncing Dictionary, ,

Morten — Nurse's Dictionarv, . . .

II
II

18
3«

16
20

5
12

EYE, EAR, NOSE, AND THROAT.

An American Text- Book of Diseases
of the Eye, Ear, Nose, and Throat, .

De Schweinitz — Diseases of the Eye, .

Gleason — Essentials of Dis. of the Ear,

Jackson — Manual of Diseases of Eye, .

Jackson and Gleason — Essentials of
Diseases of the Eye, Nose, and Throat, 16

Kyle — Diseases of the Nose and Throat, 1 7

GENITO-URINARY.

An American Text-Book of Genito-
urinary and Skin Diseases, 6

Hyde and Montgomery — Syphilis and

the Venereal Diseases, 15

Martin — Essendals of Minor Surgery,

Bandaging, and Venereal Diseases, . 18
Saundby — Renal and Urinary Diseases, 26
Senn — Genito- Urinary Tuberculosis, . 27
Vecki — Sexual Impotence, 30

GYNECOLOGY.

American Text- Book of Gynecolc^y
Cragin — Essentials of Gynecology,
Garrigues — Diseases of Women, .
Long — Syllabus of Gynecology, .
Penrose— Diseases of Women, . .
Pryor — Pelvic Inflammations, . .
Sutton and Giles — Diseases of Women,

0
II
IS
»7

MATERIA MEDICA, PHARMACOL-
OQY, AND THERAPEUTICS.

An American Text-Book of Applied

Therapeutics 5

Butler — Text- Book of Materia Medica,

Therapeutics and Pharmacology, . . . 10

Cema — Notes on the Newer Remedies, i«>

Griffin — Materia Med. and Therapeutics, 1 4
Morris — Essentials of Materia Medica

and Therapeutics, . . 19

Saunders* Pocket Medical Formulary, 20

Sayre— Essentials of Pharmacy, ... -:<'
Stevens — Essentials of Materia Medica

and Theraj>eutics, 2S

Stoney — Materia Medica for NupnCs. . . ^o
Thornton — Dose- Hook and Manual of

Prescription- Writing, ;o

MEDICAL JURISPRUDENCE AND
TOXICOLOGY.

Chapman — Medical Jurisprudence and
Toxicology, . . . . . . lo

Semple — Essentials of l^t-gal Medicine,
Toxicology, and Hygiene, j;

Medical Publications of W. B. Saunders & Co. 33

NERVOUS AND MENTAL

DISEASES, ETC.

Burr — Nervous Diseases, 9

Chapin — Compendium of Insanity, . . 10
Church and Peterson — Nervous and

Mental Diseases, 10

Shaw — Essentials of Nervous Diseases

and Insanity, ..28

NURSING.

Qriffith— The Care of the Baby, . . . 14

Hampton — Nursing, 14

Hart — Diet in Sickness and in Health, 15

Meigs — Feeding in Early Infancy, . • 19

Morten — Nurse's Dictionary, .... 20

Stoney — Materia Medica for Nurses, . . 30

Stoney — Practical Points in Nursing, . 29

Watson — Handbook for Nurses, ... 31

6
8

9
12

15
20

OBSTETRICS.

An American Text-Book of Obstetrics,
Ashton — Essentials of Obstetrics, . .
Boisliniire— Obstetric Accidents, . .
Dorland— Manual of Obstetrics, • .
Hirst— Text-Book of Obstetrics, . .
Norria — Syllabus of Obstetrics, . . .

PATHOLOGY.

An American Text-Book of Pathology, 7
Mallory and Wright — Pathological

Technique, 18

Semple — Essentials of Pathology and

Moibid Anatomy, 27

Senn — Pathology and Surgical Treat-
ment of Tumors, 27

Stengel— Text-Book of Pathology, . . 28
Warren — Surgical Pathology andThera-
peutics 31

PHYSIOLOGY.

An American Text-Book of Physi-
ology,

Hare — Essentials of Physiology, . . .
Rajrmond — Manual of Physiology, . .
Stewart — Manual of Physiology, . . .

PRACTICE OF MEDICINE.

An American Text-Book of the The-
ory and Practice of Medicine, ....

An American Year-Book of Medicine
and Surgery,

Anders— Text-Book of the Practice of
Medicine, g

Lockwood— Manual of the Practice of
Medicine, .

Morris — Essentials of the Practice of
Medicine,

Stevens — Manual of the Practice of
Medicine, 20

SKIN AND VENEREAL.

An American Text- Book of Genito-
urinary and Skin Diseases, 5

Hyde and Montgomery — Syphilis and
the Venereal Diseases, 15

14
21

Martin — ^Essentials of Minor Surgery,
Bandaging, and Venereal Diseases, . ig

Pringle— Pictorial Atlas of Skin Dis-
eases and Syphilitic Affections, ... 21

Stelwagon — Essentials of Diseases of
the Skin, 28

SURGERY.

An American Text- Book of Surgery, 7
An American Year-Book of Medicine

and Surgery, 8

Beck — Fractures, g

Beck — Manual of Surgical Asepsis, . . 9
DaCosta — Manual of Surgery, . ... 12
International Text-Book of Surgery, . 15

Keen— Operation Blank, 17

Keen — The Surgical Complications and

Sequels of Typhoid Fever, 17

Macdonald — Surgical Diagnosis and

Treatment, 18

Martin — Elssentials of Minor Surgery,

Bandaging, and Venereal Diseases, . 18
Martin — Essentials of Surgery, .... 18

Moore — Orthopedic Surgery, 19

Nancrede — Principles of Surgery, . . 20
Pye — Bandaging and Surgical Dressing, 21
Scudder — Treatment of Fractures, . . 26
Senn — Cienito- Urinary Tuberculosis, . 27

Senn— Syllabus of Surgery, 27

Senn — Pathology and Surgical Treat-
ment of Tumors, 27

Warren — Surgical Pathology and Ther-
apeutics, 31

URINE AND URINARY DISEASES.

Saundby — Renal and Urinary Diseases, 26
Wolfif^ Essentials of Examination of
Urine, 31

MISCELLANEOUS.

Abbott — Hygiene of Transmissible Dis-
eases, 8

Bastin — Laboratory Exercises in Bot-
any, 9

Gould and Pyle — Anomalies and Curi-
osities of Medicine, 13

Grafstrom — Massage, ....... 14

Keating — How to Examine for Life

Insurance, » 16

Rowland and Hedley — Archives of

the Roentgen Ray, 21

Saunders* Medical Hand- Atlases, . 2, 3, 4
Saunders' New Series of Manuals, 24, 25
Saunders* Pocket Medical Formulary, 26
Saunders* Question-Compends, . . 22, 23
Senn — Pathology and Surgical Treat-
ment of Tumors, .27

Stewart and Lawrance — Essentials of

Medical Electricity, 29

Thornton — Dose- Book and Manual of

Prescription-Writing, 30

Van Valzah and Nisbet— Diseases of
the Stomach, ^ci

BOOKS JUST ISSUED*

THE AMERICAN ILLUSTRATED MEDICAL DICTIONARY.

For Students and Practitioners* A Complete Dictionary of the Terms used in Medi-
cine and the Allied Sciences, with a large number of Valuable Tables and Numerous
Handsome Illustrations. Edited by W. A. Newman Dorland, M. D., Editor of the
American Pocket Medical Dictionary. Handsome large octavo, 800 pages, bound in
full limp leather, and printed on thin paper of the finest quality, forming a handy
volume, only l)( inches thick.

This is an entirely new and unique work, intended to meet the need of practitioners and students for a
complete, up-to-date dictionary of moderate price. The book is designed to furnish a maximum amount of
matter in a minimum space and at the lowest possible cost. It contains double the materi&l in the ordinary
students' dictionary, and yet. by the use of a clear, condensed type and thin paper of the finest quality, is only
lyi inches in thickness. It is bound in full flexible leather, and is just the kind of a book that a man will want
to keep on his desk for constant reference. The book makes a special feature of the newer words, and
defines hundreds of important terms not to be found in any other dictionary. It is especially full in the
matter of tables, containing more than a hundred of great practical value. A new feature is the inclusion
of numerous handsome illustrations, many of them in colors, drawn and engraved specially for this book.
These have been chosen with great care and add infinitely to the value of the work. The book will appeal
to both practitioners and students, since, besides a complete vocabulary, it gives to the more important
subjects extended consideration of an encyclopedic character.

B6HM, DAVIDOFF, AND HUBER'S HISTOLOGY.

A Text-Book of Human Hi8tolos:y. Including Microscopic Technic. By Dr.
A. A. BuHM and Dr. M. von Davidoff, of Munich, and G. C. Huber, M. D.,
Junior Professor of Anatomy and Histology, University of Michigan.

FRIEDRICH AND CURTIS ON THE NOSE, THROAT. AND EAR.

Rhinolos:y, Laryns:olos:y, and Otolos:y in their Relations to Qeneral
Medicine. By Dr. E. P. Friedrich, of the University of Leipsig. Edited by
H. HoLBROOK Curtis, M. D., Consulting Surgeon to the New York Nose and Throat
Hospital.

LEROY'S HISTOLOGY.

The Essentials of Histology. By I.ouis Leroy, M. D., Professor of Histologj-
and Pathology, Vanderbilt University, Nashville, Tennessee.

OODEN ON THE URINE.

Clinical Examination of the Urine. By J. Bergen Ogden, M. D.. Assistant

in Chemistry, Harvard Medical School. Handsome octavo volume of over 408 jages,
with 54 illustrations and 1 1 full-page plates, many in colors.

PYLE'S PERSONAL HYGIENE.

A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D.. Assist-
ant Surgeon to Wills Eye Hospital, Philadelphia. Octavo volume of 344 pages,
fully illustrated.

SALINGER AND KALTEYER'S MODERN MEDICINE.

Modern Medicine. By Julius L. Salinger, M. D., Demonstrator of Clinical
Medicine, Jefferson Medical College, and K. J. Kalteyer, M. I)., Assistant Demon-
strator of Clinical Medicine, Jefferson Medical College. Handsome octavo volume of
over 800 pai^es, fully illustrated.

STONEY'S SURGICAL TECHNIC FOR NURSES.

Surgical Technic for Nurses. By Emily A. M. Stoney. late Superintendent
of the Training-School for Nurses, Carney Hospital, South Boston, Massachusetts.

Ill

FL'^-

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